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an'iI 



SCHOOL HEALTH 
ADMINISTRATION 



BY 



LOUIS W. RAPEER, M.A., Ph.D. 

rv^W YORK TRAINING SCHOOL FOR TEACHERS 



PUBLISHED BY 

tE^eacljerg College, Columbia ^nibersJitp 

NEW YORK CITY 

1913 



i^v 






Copyright^ 1913, by Louis W. Rapeer 



THE HOWARD-GEAY CO., PRINTEES, 
NEW YORK CITY 



SlCI,A358239 



PREFACE 

The problem of this dissertation is to find what Ameri- 
can cities are doing for national health and vitality through 
the agency of the public schools, and how this work may 
be made more efficient and socially useful in solving our 
individual and national health problems. The scope of the 
work is enormous and necessarily in the nature of a rough 
survey, rather than an intensive study of a narrow portion 
of the field. Only one of the newest phases of educational 
hygiene, medical inspection of schools, has been very thor- 
oughly investigated, and the multiplicity of limitations in 
this field has made great accuracy impossible. No very 
conclusive results have been obtained, and the volume is 
offered merely as a beginning on a new problem, and for its 
suggestive value in practical administrative improvement. 

The investigation began with the practice of such work 
in the writer's own school when a principal in Minneapolis, 
and more directly with a study of data collected by the 
Child Hygiene Department of the Russell Sage Founda- 
tion on the health provisions of 1,038 graded school systems 
under superintendents. It has since broadened into a study 
of national health and vitality, a survey of educational 
hygiene in twenty-five of forty cities visited for the pur- 
pose, and an intensive study of health problems in one 
school system by invitation of the Board of Education. 
The tentative standard plan for the administration of medi- 
cal inspection as an organic part of the whole of educational 
hygiene here offered for criticism, is an outgrowth of the 
last mentioned study. The hope back of the dissertation is, 
of course, that the health conditions of our nation may 
be improved. 

3 



4 PREFACE 

To prosecute such an investigation requires the co-oper- 
ation of a great number of individuals. In this case, super- 
intendents, school physicians and nurses, dentists, directors 
of physical education, members of state and local boards 
of education, health officers, principals, teachers, school 
janitors, and business managers, in great numbers, in the 
twenty-five cities especially, have cheerfully contributed to 
make the study possible. For their never-failing courtesy 
and unstinted helpfulness I here publicly give grateful 
acknowledgment. To Professors George D. Strayer, Ed- 
ward L. Thorndike, and Henry Suzzallo of Teachers Col- 
lege, Columbia University, and to Doctor Leonard P. 
Ayres of the Child Hygiene division of the Sage Founda- 
tion, the author is much indebted for encouragement and 
many valuable constructive suggestions. My wife has con- 
tributed at every step to make the study possible. 

22a..W. I20th Street, . ^ fT^ • i ^^ dji/'t 

New York City, fe S»t T^ > «i 5<u.» ** "" * •- 

Sept., 1913. tMt^^it QM^'^t^ n\el, 



CONTENTS 

Outline Abstract 7 

PART ONE 

The National and School Health Problem and 
How It is Being Met 

Chapter 

I. The National Health Problem 17 

II. The School Health Problem 28 

III. How THE Health Problem is Being Met 

IN Schools and Nation. 

54 

PART TWO 

How the Problem of Educational Hygiene is Being 
Solved in Twenty-Five Cities 

IV. General Phases of Health Administra- 

tion 71 

V. The Nature and the Efficiency of the 

Work Done 107 

VI. The Ailments of Public School Chil- 
dren. A. Physical Defects 134 

VII. B. Common Non-Infectious Ailments.. 182 

VIII. C. & D. Communicable Ailments, Para- 
sitic AND Infectious 203 

IX. Special Phases of Medical Inspection in 

These Cities 228 

X. Physical Education and Other Phases 

OF Educational Hygiene 262 

PART THREE 

XI. The Administration of Medical Inspec- 
tion — A Tentative Standard Plan. . . 295 

5 



Number. 
I. & II. 
III. 

IV. 

V. 

VI. 

VII. 

VIII. 

IX. 
X. 

XI. 

XII. 

XIII. 

XIV. 

XV. 

XVI. 

XVII. 

XVIII. 

XIX. 



TABLES AND FORMS 

Page. 
Causes of Death in the Registration Area. .22-23 
Preventability of Death of Elementary 

School Children 29 

Preventability of Deaths of High School 

Children 30 

General Administration of Medical Inspec- 
tion 76-77 

The Work of Doctors and Nurses 80-81 

Accom-plishment in Medical Inspection. . 116- 1 17 
Ailments of School Children. Physical De- 
fects 138-139 

Common Non-Infectious Ailments. . 184- 18 5- 186 
Communicable Ailments, Parasitic and In- 
fectious. Deaths of Children. .. .205-206-207 

Ailments in Order of Frequency 226-227 

Efficiency Data. Estimated Needs of Cities 253 

Approximate Rank of the Cities 254 

Physical Education 263 

Divisions of Educational Hygiene 296 

Individual Health Record, Number One.. 311 
Individual Health Record, Number Two. . 315 
Weekly Report of Doctors and Nurses. .345-346 
Classification and Frequency of Ailments.. 351 



SCHOOL HEALTH ADMINISTRATION 

OUTLINE ABSTRACT 
I. GENERAL METHOD OF THINKING 

In general, the thought is that before we can say what 
the pubHc schools are or should be doing for individual 
and public health we must determine as accurately as 
possible with present-day statistics what the health needs 
and problems of individuals and the nation actually are, 
and how serious the health problem is, compared with other 
grave problems of life. The public school's share in the 
responsibilities for public health amelioration is very great, 
and growing, due to the lack or inefficiency of other insti- 
tutions for such a purpose, to the admirable conditions of 
control in a state institution and with compulsory attend- 
ance and general community support, and to the fact that 
such a large share of health mal-adjustment is due to health 
ignorance, and the lack of adequate health habits and ideals 
which it is so largely the special function of the public 
school to replace with positive health qualities. The princi- 
pal problems of life, whatever they may be, and to be 
discovered only by a study of life through surveys or any 
other efficient means, furnish the problems of public edu- 
cation. 

II. PART ONE. THE NATIONAL AND SCHOOL HEALTH PROB- 
LEM AND HOW IT IS BEING MET IN SCHOOL AND 
NATION. (summarized AT END OF CHAP- 
TERS TWO AND THREE.) 

Health and physical vitality are all-important to the 

attainment of the goal of life (happiness through social 

efficiency), but they are being very poorly provided for, 
since : 



8 SCHOOL HEALTH ADMINISTRATION 

A. The national health losses are enormous and largely 
preventable, for: 

1. Approximately 1,600,000 of our population die each 
year, 42 per cent, or about 670,000, of reasonably 
preventable diseases. The economic loss in deaths 
is approximately a billion dollars. 

2. Approximately 3,000,000 persons are constantly 
seriously /// in the United States, largely of prevent- 
able diseases ; and this occasions an economic loss of 
about another billion dollars. 

3. A very large number of persons suffer from many 
minor ailments which lower their efficiency and cause 
absence from work, which makes an economic loss 
of another very large sum. 

4. Other nations, such as Sweden and Germany, are 
succeeding by adequate national and school provi- 
sions in lowering the losses much below our own. 

5. Competent authorities have estimated in various 
ways the large preventahility of these losses by 
reasonable application of present knowledge. 

6. Such preventahility can be seen from the effects of 
such civic improvements as pure water and pure 
milk supplies. 

B. The school health losses are enormous and largely 
preventable, for : 

1. Approximately 100,000 children of elementary and 
high school age die each year in the United States, 
65,000 of whom have been during the year en- 
rolled in a pubhc school. Of these 40,000 and 
perhaps 50,000 are reasonably preventable. Their 
education has been socially wasted expenditure of 
energy and money. 

2. The illness losses of both teachers and pupils of the 
public schools are enormous, coming in the form 
of personal and public financial loss, of lowered 
vital efficiency and happiness, and of elimination, 
non-promotion and retardation at school. Tentative 
guesses at the amount of each of these last three 



SCHOOL HEALTH ADMINISTRATION 9 

due to Illness as the chief or only factor are : elim- 
ination, about 12 per cent; non-promotion, about 
II per cent; retardation, about 10 per cent. 

3. The physical defects losses are also enormous and 
largely preventable. They function largely in caus- 
ing about: five per cent of elimination, six per cent 
of non-promotion, and seven per cent of retarda- 
tion. 

4. Combined, the two factors of ill-health and physical 
defects function largely in causing about: 15 per 
cent of elimination, 16 per cent of non-promotion, 
and 17 per cent of retardation. 

5. These results are not the only ill-health results, of 
course, but whenever these are related to the 
twenty million school children in the United States, 
the problem of school health stands out as one of 
the greatest before the public. 

6. The studies reviewed for their school health data 
here are : Strayer's Introductory Survey to the 19 10 
Report of the U. S. Bureau of Education, Fisher's 
National Vitality, U. S. Mortality Statistics for 
19 10, Dr. Keyes' "Progress Through the Grades 
of City Schools," the studies of Retardation by 
Ayres, Strayer and Thorndike, Dr. Bachman's re- 
port in the New York City School Inquiry of 
"Promotion, Non-Promotion and Part Time," Supt. 
Demarest's 19 11 Study, the Boston Non- Promotion 
Study, Supt. Broome's 191 1 Study, Supt. Mackey's 
19 II Study, Supt. Verplanck's 191 1 Study, Supt. 
Brubacher's 191 1 Study, the Newark Quarantine 
and Absence Reports, the Ayres, Cornell, and Wal- 
lin studies, and a few others. 

7. This phase has not been exhaustively studied be- 
cause the crux of the investigation is the work of 
the twenty-five cities. Other data to emphasize, by 
facts, the health problem of schools could easily be 
furnished and are given in the later study of the 
ailments of school children. 



10 SCHOOL HEALTH ADMINISTRATION 

C. The national provisions for public health, in the fed- 
eral, the state, and local governments are comparatively 
numerous, heterogeneous, and entirely inadequate to meet 
the national health needs and problems. 

Likewise the school provisions for public health are 
numerous, growing, heterogeneous and entirely inadequate, 
both as to quantity and to efficiency, to solve satisfactorily 
the school health problem. The science and the practice 
of educational hygiene are in their infancy. 

Many of the agencies and a large number of other facts 
relating to national, school, and private provisions for public 
health are concisely stated in chapter three. 

Among the most important agencies to work for are : 
The national, state, and local departments of health and 
their increased scope and greatly improvable (the last two) 
efficiency, and, secondly, efficient and scientific departments 
of Educational Hygiene in federal, state, and local school 
systems with the following working divisions : medical in- 
spection, the teaching of hygiene, school sanitation, physical 
education, and the hygiene of teaching. The promise for 
the greatest usefulness lies in such departments under expert 
direction. 

III. INVESTIGATION OF EDUCATIONAL HYGIENE IN 
TWENTY-FIVE CITIES 

A. The method was to visit forty cities and select from 
these twenty-five that had both school doctors and nurses 
and had had the work in progress for nearW a year or 
longer. Most of the visits were made in 191 1, but for wide 
acquaintance with the work they have been continued when- 
ever time could be found from the fall of 19 10 to the 
spring of 1913. One city was intensively studied for the 
Board of Education of that city. All reports, blank forms, 
the methods of work, and all public provisions for public 
health In charge of the school or other organizations dealing 
with school children were studied so far as data could be 
found and time permitted. The work is in the form of 
a survey with some intensive study of several phases, and 



SCHOOL HEALTH ADMINISTRATION ii 

the motive has been to avoid any tendency toward muck- 
raking and to make the study entirely constructive. The 
writer was prejudiced against board of health control of 
medical inspection at the start, and this has been offset 
by giving these bodies especially favorable consideration 
throughout. 

B. The work of medical inspection is in its infancy and 
is yet very heterogeneous and inefficient. The organization is 
poor and the amount of money spent not commensurate 
with the needs, as compared with other legitimate needs. 

C. Board of Health control of this work, even though 
it has some marked advantages, is, on the whole, less efficient 
and less promising for the future than Board of Education 
control. 

D. Medical inspection is at present isolated from other 
phases of educational hygiene. Many promising features 
of the development of the four other phases of educational 
hygiene in these cities are given in chapter ten. 

E. The chapters on the ailments of school children 
give a close view of the fifty-four classes of ailments accord- 
ing to the tentative standard classification presented, and 
attempt to state the probable frequency of such ailments in 
an elementary school population that has not had long and 
efficient medical supervision. Our estimates are much lower 
than those usually given. 

F. The reader is here referred to the summary of con- 
clusions regarding medical inspection found in chapter nine, 
in the tables, and especially in the tentative standard plan 
for the administration of this work. 

IV. TENTATIVE STANDARD PLAN FOR THE ADMINISTRATION 
OF MEDICAL INSPECTION 

A. The plan here offered, and later to be re-printed for 
separate use, is intended to be applicable as a beginning 
for most cities, for rural areas, and for any group of 
small cities. It has been critically tested in part by a com- 
mittee that has studied the systems of reporting and ad- 
ministration in seventy-five cities, and is believed to be 



12 SCHOOL HEALTH ADMINISTRATION 

superior to any system now in operation; and may be put 
into operation at practically the same expenditure of money 
as any well-provided city on present lines. 

B. Every administrative area, a city, a group of cities, 
or a rural area such as a district, township, or county, 
depending upon the number of children, should have a 
director, or supervisor, of (educational) hygiene. Over 
these, each state should have a supervisor of hygiene. This 
officer should have the qualifications both of a physician 
and of a specialist in educational hygiene. Such men are 
now to be had, and indications point toward the introduc- 
tion of training courses for doctors of educational hygiene 
in medical schools and teachers' colleges. The salary at 
present must be, at least, between two and four thousand 
dollars a year, of eleven months. The supervisor's function 
will be to correlate and supervise all phases of hygiene 
(medical inspection, physical education, school sanitation, the 
teaching of hygiene, and the hygiene of teaching) , in con- 
junction with the general superintendent, and in many cases 
to do part of the work of medical inspection. In many 
systems the number of part-time school physicians, phy- 
sical training teachers and truant officers who can be elim- 
inated will be great enough to make necessary little or no 
increase of expenditure for his salary. Many other savings 
through such a system will be evident. 

C. At present, no good plan for the complete elimina- 
tion of part-time work on the part of assistant school phy- 
sicians has been devised, although this is to be desired. 
The plan here is to have physicians do practically no other 
work than that of the (physical) examination of pupils, 
and to have the supervisor of hygiene, where possible, do 
the work of one physician. To begin with, have one 
physician, counting the supervisor, for each three thousand 
children, elementary and high school, and one nurse for 
each two thousand children, depending upon circumstances 
as to the exact numbers. Have the physicians give two 
hours a day in one school building each, making medical 
examinations of the pupils (also teachers and janitors) and 



SCHOOL HEALTH ADMINISTRATION 13 

such individual inspections as are urgent, and completing 
the examination of the allotted number of pupils, with the 
help of an assisting nurse, before the end of the school year. 
The nurses are to do most of the inspecting, aside from 
the routine September room-inspection of all children, and 
also the home visiting. 

D. The details of the work are given in the plan. The 
reporting and record system should be adapted and adopted, 
including the tentative standard classification of school ail- 
ments. The doctor has no traveling about from school 
to school on school time to do, and he is likewise freed 
from making reports. Clerical work is almost entirely 
placed in the hands of the nurse. This is the greatest piece 
of economy in the entire plan, when seen in comparison 
with present systems, many of them requiring far more 
time at clerical work, and inter-school traveling than in 
actual school medical service. 

E. The nurse-alone plan is probably best in very poor 
districts, unable to provide a complete system. Later, phy- 
sicians can be added. This is the direct opposite of the 
usual plan, of employing physicians and then, if possible, 
adding nurses. The nurse's service is usually cheap, efficient, 
and directed toward getting the results that count: preven- 
tion and cures. So far as inspection goes, nurses are able 
to find most of the serious cases needing care and treat- 
ment. We very much need better training of nurses for 
school work, but not any more than we need such train- 
ing for school physicians. We prophesy that well-trained 
school nurses will soon take the place of part-time physicians 
in medical supervision. There will be a supervisor of 
hygiene with assistants, and physicians in school clinics. 

F. The plan as here offered for trial is not guaranteed 
perfect. It is very imperfect, and nothing will take the 
place of careful study of local conditions, careful adaptation 
of this and other plans, and careful training of doctors, 
nurses, teachers, and pupils in carrying it out efficiently. 
The skilled medical supervisor will be necessary for this 
work with any plan, and scientific supervision and study will 
be sure to bring health results. 



EXPERIMENTAL EDUCATION FOR 
SCHOOL PROBLEMS 

"My first and in some respects my deepest im- 
pression of the evening spent so enjoyably in 
Edison's laboratory is not directly connected with 
the educational value of his motion picture 
scheme. It is rather of the immense advantage 
a great commercial enterprise has over the great- 
est of our existing educational institutions in the 
matter of conducting systematically an experi- 
mental development of a new proposal before 
putting it into general practice. 

"No intimation zvas given of the sum of money 
that is being put into the development of this 
new undertaking. But it is clear that a large 
staff is employed to develop 'scenarios' to make 
suggestions and criticisms, and to try out various 
schem,es, in addition to the expense involved in 
taking the pitcures themselves. A large sum of 
money will have been spent before pecuniary 
returns begin to come in — a good deal of it strict- 
ly experimental inquiry. 

"Where is there a school system having at 
command a sum of money with which to investi- 
gate and perfect a scheme experimentally, be- 
fore putting it into general operation? And can 
we expect continuous and intelligent progress in 
school matters until the community adopts a 
method of procedure which is now a common- 
place with every great industrial undertaking? 
Is not the existing method of introducing re- 
forms into education a relic of an empirical cut- 
and-try method which has been abandoned in 
all other great organisations? And is not the 
failure to provide funds so that experts may 
work out projects in advance a pennywise and 
poundfoolish performance?" — John Dewey, in 
the Survey for September 6, 1913. 



PART ONE 

THE NATIONAL AND SCHOOL HEALTH PROBLEM 
AND HOW IT IS BEING MET 



THE NATIONAL HEALTH PROBLEM 

"In the continental United States with over 90 
million souls probably 23^ million children are 
annually born. When we think of the influence 
of a single man in this country, of a Harriman, 
of an Edison, of a William James, the poten- 
tiality of these 25^ million annually can be dimly 
conceived as beyond computation. But for bet- 
ter or worse this potentiality is far from being 
realised. Nearly half a million {one- fifth) of 
these infants die before they attain the age of 
one year; and half of all are dead before they 
reach their twenty-third year — before they have 
had much chance to affect the world one way 
or another. However, with only one and a 
quarter million of the children born each year — 
destined to play an important part for the nation 
and humanity we could look with equanimity on 
the result. But alas! only a small part of this 
army will be fully effective. On the contrary, 
of the 1200 thousand who reach full maturity 
each year 40 thousand will be ineffective through 
temporary sickness, 4 ^0 5 thousand will be 
segregated in the care of institutions, unknown 
thousands will be kept in poverty through mental 
deficiency, other thousands will be the cause of 
social disorder and still other thousands will be 
required to tend and control the weak and un- 
ruly. We may estimate at not far from 100 
thousand, or 8 per cent., the number of non- 
productive or only slightly productive, and prob- 
ably this proportion would hold for the 600 
thousand males considered by themselves." — 
Davenport, in "Heredity in Relation to Eu- 
genics." 



CHAPTER ONE 
THE NATIONAL HEALTH PROBLEM 

I. EDUCATION AND PUBLIC HEALTH 

Health is the fundamental prerequisite for both indi- 
vidual and social happiness and efficiency. It stands in such 
intimate and vital relationship to existence itself and to the 
first law of life, self-preservation, that it must ever be a 
foremost problem of individual and social policy. The 
primary business of a sick man is to get well and to stay 
well; likewise, the primary business of the public and the 
state is to provide for healthful conditions and healthy lives. 
Private and social practice which preserves and promotes 
health and abundant life is, from this standpoint, good; 
that which contributes to ill-health or race-degeneracy, 
though it bring forth some of the best of the goods of life, 
is wrong. Theoretically, at least, everyone will agree with 
the thought emblazoned in great letters over the stage in 
Der Mensch building at the recent International Hygiene 
Exhibition at Dresden: No Wealth Is Equal to Thee, 
O Health.i 

That a very much larger proportion of people than nec- 
essary are not realizing this great eternal value of life, 
good health, is also a matter of common knowledge. The 
progress of medical and sanitary science in the last fifty 
years has brought, one by one, most of the insidious destroy- 
ers of life and health into the light of day. These discov- 
eries have not only overturned hoary health traditions, such 
as the commonly accepted opinion that malaria and yellow 
fever were caused by "night air" instead of by the bills 
of certain ubiquitous mosquitoes, but they have followed 

17 



1 8 SCHOOL HEALTH ADMINISTRATION 

each other in such rapid succession that health science, 
known by the few, is today, at least twenty, and in many 
ways forty, years ahead of common knowledge and general 
practice.^ It is the purpose of this chapter to face the health 
problem of the nation and, so, of the schools, endeavoring 
to determine something of its nature and extent and the 
responsibility it places upon public school systems. 

Probably the most important scientific studies of public 
health in America recently are Professor Fisher's "National 
Vitality"^ and Flexner's "Medical Education in the United 
States and Canada"'^ ; the first, by the statistical methods 
evolved by the great life insurance companies, outlining 
the enormous extent and the tremendous importance of the 
problem ; and the second, by personal visitation and scientific 
methods, determining the almost criminal inadequacy of 
many of the present instruments for providing health lead- 
ers.^ In the first is given at length the evidences and facts 
relating to the improvability of health conditions in this 
country. Fisher shows the methods by which eighteen ex- 
perts in various diseases, mortality statistics, and sanitary 
science determined the ratio of preventability for the ninety 
different causes of death into which mortahty is classified. 
This ratio is defined as "the fraction of all deaths which 
would be avoided if knowledge now existing among well- 
informed men in the medical profession were actually ap- 
plied in a reasonable way and to a reasonable extent."^ That 
the ratios thus determined are careful, conservative figures, 
not implying, for example, any advance in medical discov- 
eries nor the complete socialization of health knowledge 
now possessed by the few, an inspection of his table of 
ratios will quickly show. Most persons, perhaps, would In- 
crease many of these ratios, since the race is slowly coming 
to take the view expressed by Pasteur when he said that 
"it is within the power of man to rid himself of every para- 
sitic disease." We have reason to believe in "the improv- 
ability of man," and we know that the first step and con- 
dition of such conscious evolution is health and life itself. 



NATIONAL HEALTH PROBLEM 19 

II. NATIONAL HEALTH LOSSES 

A. In Preventable Deaths 

The recently published federal "Mortality Statistics"^ 
for the year 19 10 show that in the "registration area" 
of continental United States over eight hundred thousand 
persons died (805,412). The registration area consists of 
those states and cities that are conscious enough of their 
health problems to enforce such recording of deaths as will 
be accepted by the Census Bureau.^ This area consists of 
twenty-two states, counting the District of Columbia 
(City of Washington) as a state, and forty-three cities in 
non-registration states, and including about three-fifths of 
the population of continental United States (53,843,896 out 
of 92,309,348 or 58.3 per cent).^ The registration area for 
births is very much smaller. 

It is impossible, then, for the people of the United 
States, as contrasted with several modern nations, to know 
accurately either the national birth rate or death rate. Com- 
paratively lax enforcement of registration laws in many 
places makes even the statistics from the registration area 
underestimates. The statistical death rate of this area for 
the year 19 10 is, however, 15 per 1000 population, the 
annual average for ten years being about sixteen ; and, for 
the year 1910, 16. i in registration cities, 14.7 in registra- 
tion states, 15.9 in cities of registration states, 13.4 in the 
rural portion of registration states, and 16.9 in the regis- 
tration cities of other states.^" Wilcox estimates the true 
average death rate for the United States as 18 a thousand. -^^ 

Using the ratio of registration-area population to the 
total population, 58.3 per cent, and the number of deaths 
occurring in the registration area, 805,412, we can com- 
pute the probable death loss for the country. Or, we can 
find what an average death-rate of fifteen a thousand would 
mean for the entire population, 92,843,896 (July i, 19 10, 
estimate). From such computation we get a total death 
loss to continental United States of 1,392,660. Applying 
the estimate of Wilcox, 18, we obtain a loss of 1,671,228, 
Professor Fisher considers 18 as a minimum true rate, and 



20 SCHOOL HEALTH ADMINISTRATION 

this seems reasonable, so a death loss for 19 lo of 1,600,000 
seems entirely conservative, and would probably be, too, 
very near the average number of deaths year by year. In 
other words, a little less than two per cent of our total pop- 
ulation dies each year, and at the exceedingly low median 
age of 38.^^ How much of this astounding death loss is 
unnecessary and preventable we shall now tr3^ to see. 

PREVENTABLE VITAL AND ECONOMIC LOSSES 

The average ratio of preventability for these death 
losses, as computed by Fisher from the combined conser- 
vative estimates furnished by the eighteen experts, ranging 
in eighteen cases from zero for such diseases as epilepsy 
to 85 per cent preventable for typhoid fever, alcoholism, 
and puerperal septicemia. Is found to be 42.3 per cent.^^ In 
other words two-fifths of the deaths now occurring in the 
United States are reasonably preventable or postponable. 
With the advance of medical science each year this ratio 
will rise. Even as the above lines were being written, 
March 22, 19 12, word came from the United States Hy- 
gienic Laboratory that Director Anderson and Surgeon 
Goldberger had scientifically demonstrated that the "prin- 
cipal, if not the only, means of spreading typhus fever" was 
pediculae (head lice), the trouble found more frequently 
and more commonly in most cities by medical inspectors of 
schools than any other ailment, with the exception of den- 
tal carles. ^^ 

Applying this figure, 42 per cent, to the estimated num- 
ber of deaths each year we get as the number of pre- 
ventable deaths occurring annually, 672,000. 

What does the preventable and unnecessary loss of life 
of over 670,000 persons in a normal year mean in anguish, 
illness, and money to the people of the United States? 
The psychological losses of this character, although the 
most terrible of earth's sorrows, we are as yet unable to 
estimate. The average family is about four, so, at least, 
three times as many persons (2,010,000) annually are ex- 
tremely intimately and seriously affected. 



NATIONAL HEALTH PROBLEM 21 

ECONOMIC DEATH LOSSES 

Various methods of computing the economic losses have 
been worked out. Doctors Locke and Floyd of the Out- 
Patient Department of the Boston Consumptives Hospital 
have recently patiently investigated the economic loss re- 
sulting from 500 male consumptives, who had visited the 
hospital in the last five years. ^^ The capitalized value of 
the earnings cut off by the deaths of 244 of the men is 
computed as about a million and a half dollars, or an 
average of about $6,164 each. 

Professor Fisher's calculated "average economic value 
of the lives now sacrificed by preventable deaths, using the 
age distribution of deaths, and the percentages of preven- 
tability" is $1700 each.^^ 

For the 670,000 preventable deaths in this country in 
19 10, we should have a financial loss to the nation equal to 
the product of these two figures (670,000 times $1700) 
which is $1,139,000,000, considerably over a billion dollars. 

The accompanying table and summary have been made 
by condensing the U. S. Mortality Statistics which give 189 
causes of death. Table II, given in italics, is here included. 
B. National Illness Losses. Vital and Economic 

But many are ill for each one who dies. "Few who have 
not studied the facts realize how common illness is, although 
we all know it is sufficiently common to make the question 
'How are you?' the ordinary form of salutation." The 
above mentioned Report of the National Conservation Com- 
mission on National Vitality (page 741) furnishes the 
estimate that in the United States there are constantly three 
million persons on the sick list. It is computed that 750,000 
of these cases (in 1907) are those of persons thrown out 
of employment by their illness. The average earnings, 
computed as $700 a year, lost each year in this way would 
then be 750,000 times $700, which is over $500,000,000, 
a half billion dollars. 

If we take more recent statistics of annual wages and 
the present amount of illness, we obtain other figures. Pro- 
fessor Scott Nearing computes from a wide study of our 
wage statistics in industrial sections "that half of the adult 



22 SCHOOL HEALTH ADMINISTRATION 



TABLE I. 

CAUSES OP DEATH FOR THE REGISTRATION AREA 

All Children of School Ages. 

Ages. 5 to 9 10 to 14 15 to 19 

All Causes 805,412 17,943 11,736 19,772 

I. General diseases 215,692 8,891 4,978 9,770 

1. Typhoid fever 12,673 684 854 1,681 

2. Malaria 1,167 58 40 67 

3. Small pox 202 6 6 17 

4. Measles 6,598 588 152 112 

5. Scarlet fever 6,255 1,731 442 232 

6. Whooping cough 6,146 228 17 10 

7. Diphtheria and croup 11,521 2,938 700 228 

8. Influenza 7,774 122 73 119 

9. Cholera nostras 536 14 8 7 

10. Dysentery 3,446 47 15 IS 

II. Erysipelas 2,442 8 14 35 

12. Other epidemic diseases.... 198 23 11 3 

13. Purulent infection, etc 1,877 73 62 86 

14. Rabies 64 13 9 6 

15. Tetanus 1,373 162 153 88 

16. Pellagra 368 4 5 12 

17. Tuberculosis (of lungs) 73,214 489 1,048 5,166 

18. Tuberculosis (other) 13,095 933 586 933 

19. Rickets 455 13 8 4 

20. Syphilis 3,221 24 11 36 

21. Gonococcus infection 197 . . 1 17 

22. Cancer and other m. tumors 41,039 83 76 152 

23. Other tumors 553 9 4 6 

24. Acute articular rheumatism. 3,328 327 357 261 

25. Diabetes 8,040 144 206 258 

26. Leuchemia 864 44 35 39 

27. Anemia, chlorosis 2,614 39 40 70 

28. Other general diseases 5,014 4 10 67 

11. Nervous Sys. — Special Sense 77,991 1,368 889 976 

29. Encephalitis 761 34 37 39 

30. Meningitis 7,619 683 365 294 

31. Spinal cord, other dis 4,101 264 146 130 

32. Aploplexy, cereb. hem 39,701 47 46 103 

33. Paralysis, without spec, cause 7,756 27 21 29 

34. Epilepsy 2,287 79 118 172 

35. Convulsions (nonpeuperal) . 200 54 9 18 

36. Chorea, St. Vitus Dance... 123 13 18 41 

37. Nervous system, other D. . . 2,069 70 58 63 

38. Ear diseases 967 92 64 46 

III. Circulatory System 100,106 999 1,319 1,447 

39. Pericarditis 650 32 32 14 

40. Endocarditis, acute 4,792 203 226 196 

41. Organic D. of the heart 76,178 716 1,011 1,158 

42. Angina pectoris 3,869 7 12 17 

43. Embolism and thrombosis. . 1,990 20 19 33 

44. Lymphatic system, Dis 255 14 9 9 

IV. Respiratory System 100,835 2,035 956 1,517 

45. Nasal fossae Disease 135 9 9 5 

46. Larynx, Dis. of 746 90 13 11 

47. Bronchitis, acute 7,229 90 21 21 

48. Bronchitis, chronic 5,391 62 30 36 

49. Bronchopneumonia 25,337 522 148 158 

50. Pneumonia 54,187 1,138 664 1,140 

51. Pleurisy 2,150 66 32 83 

52. Pulmonary cong't'n, P. Ap 24,499 28 17 17 

53. Other D. of Resp. System.. 1,174 16 13 28 

V. Digestive System 104,801 1,669 1,270 1,429 

54. Mouth and annexa, D 423 11 4 6 

55. Pharynx 840 123 51 40 

56. Ulcer of stomach 2,203 13 18 47 

57. Other D. of stomach (not c) 8,403 116 57 73 

58. Diarrhea and enteritis 63,180 469 132 91 

59. Appendicitis and typhlitis.. 6,128 571 718 754 

56. Hernia 2,192 8 6 21 

57. Intestinal obstruction 4,486 127 88 117 

58. Other diseases of the Intest. 1,571 25 20 22 

* Condensed from the table giving 189 different causes. 



1910.* 


Age 




group 


Total. 


f most 


5-14 


deaths 


29,679 


0- 1 


13,869 


25-29 


1,537 


20-24 


98 


20-24 


12 


0- 1 


740 


1- 2 


2,173 


5- 9 


245 


0- 1 


3,638 


5- 9 


195 


70-74 


22 


0- 1 


62 


0- 1 


22 


0- 1 


34 


0- 1 


135 


0- 1 


22 


5- 9 


315 


0- 1 


9 


30-34 


1,537 


25-29 


1,519 


20-34 


21 


0- 1 


35 


0- 1 


1 


0- 1 


3 


60-64 


13 


65-74 


684 


10-14 


350 


60-64 


79 


40-55 


79 


60-64 


14 


0- 1 


2,257 


70-74 


71 


0- 1 


1,048 


0- 1 


410 


65-69 


93 


70-74 


48 


70-74 


197 


25-29 


63 


5- 9 


31 


15-19 


128 


50-54 


156 Underl 


2,318 


65-69 


64 


65-69 


429 


55-59 


1,727 


70-74 


19 


65-69 


39 


65-69 


23 


0- 1 


299 


0- 1 


14 


0- 1 


103 


0- 1 


111 


75-79 


92 


75-79 


670 


0- 1 


1,802 


0- 1 


98 


60-64 


45 


0- 1 


29 


0- 1 


2,939 


0- 1 


15 


0- 1 


174 


5- 9 


31 


45-49 


173 


0- 1 


601 


0- 1 


1,289 


15-18 


14 


65-69 


215 


0- 1 


45 


0- 1 



NATIONAL HEALTH PROBLEM 



23 



TABLE I.- 

59. Cirrhosis of liver 7,485 

60. Other diseases of liver 3,092 

61. Peritonitis (nonpuep) 2,419 

62. Other D. of digestive system 329 

VI. Genito-urinary Sys. Nonv 62,559 

63. Nephritis acute 5,665 

64. Bright's disease 47,665 

65. Kidneys, other D. of 1,389 

66. Other D. of uterus 774 

67. Salpingitis, and other F. D. 1,298 

VII. The pueperal state 8,455 

VIII. Skin and cellular tissue. 3,008 

68. Gangrene 1,748 

69. Abscess, acute 506 

IX. Bones and locomotion organs 1,317 

70. Bones, not T. B 1,145 

71. Joints, not T. B. or Rheum. 119 

X. Malformations 7,998 

72. Hydrocephalus 685 

73. Congen. M. of heart 4,821 

XI. Early Infancy 

XII. Old age 

XIII. External Causes 57,196 

74. Suicide 8,590 

75. Accidental or undefined.... 45,416 

XIV. Ill Defined Diseases 12,462 



■Continued. 










15 


16 


25 


31 


50- 


54 


36 


35 


34 


71 


60- 


64 


132 


109 


162 


241 


20- 


24 


9 


4 


7 


13 


50- 


54 


509 


447 


780 


956 


70- 


■74 


253 


165 


199 


418 


40-44 


224 


263 


440 


487 


70- 


■74 


22 


6 


16 


28 


0- 


■ 1 


1 


5 


29 


6 


25- 


■29 


1 


2 


75 


3 


25-29 




11 


620 


11 


25- 


-29 


26 


14 


31 


40 


0- 


■ 1 


10 


7 


8 


17 


75- 


-79 


12 


5 


9 


17 


0- 


1 


100 


95 


89 


195 


0- 


. V 


93 


90 


81 


183 


0- 


• 1 


6 


4 


5 


10 


35- 


39 


76 


36 


20 


112 


0- 


- 1 


30 


11 


4 


41 


0- 


- 1 


33 


25 


13 


55 


0- 

0- 

80- 


■ 1 
• 1 

■84 


2,193 


1,678 


3,024 


3,871 


25- 


30 


1 


31 


326 


32 


35- 


39 


2,161 


1,599 


2,525 


3,760 


20- 


24 



74 



43 



68 



117 75-79 



males of the United States (at least east of the Rockies 
and north of the Mason and Dixon line) are earning less 
than $500 a year; that three-quarters of them are earning 
less than $600 annually; that nine-tenths are receiving less 
than $800 a year, while less than ten per cent receive 
more than that figure. "^'^ $5 50 or $600 w^ould then be, 
perhaps, a more characteristic figure than the $700 taken by 
Fisher. However, considering the increase In average num- 
ber of Illnesses since 1907 and the conservative character 
of the findings, we may let the annual potential-earnings- 
loss through illness stand as five hundred million dollars. 

The Nearing wage statistics, in the light of the com- 
puted minimum standards of living, will be found useful 
later on in throwing light on the cause of malnutrition 
and other ailments of school children and the necessity of 
free treatments of children in school clinics. 

The Locke and Floyd investigations, above referred to, 
show that, of the 500 male consumptive cases (41 per 
cent between the ages of twenty and thirty-nine), by May i, 



24 SCHOOL HEALTH ADMINISTRATION 

191 1, the date of the investigation, the 244 dead men had 
lost an average of 58.03 weeks of work from the onset of 
their disease until death. Their average weekly wages had 
been $11.89 and their total loss was, therefore, $170,965. 
The 256 living cases had lost an average of 89.3 weeks 
of work at an average wage of $11.38, a combined loss 
of $255,074, making a total loss in wages alone to the 
five hundred men of $426,039, an average of $852 each. 

ECONOMIC LOSSES IN MEDICAL CARE 

But lost wages are not the only illness losses. There 
is the further expenditure for medical attendance, medicine, 
nursing, etc. These five hundred sick men selected at ran- 
dom, cost the city of Boston in public hospital and other 
institutional care $73,984. This is exclusive of large sums 
spent by private organizations on 406 out of the 500 cases. 
This makes the loss of wages and cost of medical care at 
least $500,023 plainly accounted for. With the first item 
of loss-of-potential-earnings through preventable death of the 
244 men, we have a total economic loss of about $2,000,000; 
and 256 cases were not yet ended by death or cured. 

The first group lost in wages $618.28 in a year of 52 
weeks; the second group lost $591.76 in the same time. So 
we could say that the annual loss in wages for these men 
was on the average $600. The total number of weeks lost 
by both groups was 37,020, an average of 74 each. In a 
year of 52 weeks of this time, their cost to the municipality 
of Boston was about 52/74 of $73,984, or $51,988. 
This is an average cost for each man of over a hundred 
dollars a year ($103.97, practically $104). 

The cost in care to the relatives of these men and the 
cost to private philanthropic institutions is not given. 

"The cost per day or year of other illnesses than tuber- 
culosis is presumably greater, and also the cost per day for 
other classes is higher than for the poor."^^ Applying to 
the three million and more persons constantly ill in the 
United States this partial annual cost to public institutions 



NATIONAL HEALTH PROBLEM 25 

of $100 for each consumptive, we have a total annual loss 
for public care of $300,000,000. 

OTHER ESTIMATES 

A second estimate for total illness expenses to the con- 
sumptive poor, set at $1.50 a day by Dr. Biggs of New 
York, applied to the three million persons constantly ill, 
gives a total of a billion and a half dollars. 

Another estimate is based upon an investigation by the 
United States Department of Labor of five thousand work- 
ingmen's families. Their average expenditure for illness 
and death amounted to $27 a year. For the more than 
eighteen million families in the country this estimate, more 
than conservative for all classes, would make over $486,- 
000,000. The three estimates, the first and last very pains- 
takingly made, are : 

$300,000,000 estimate for public institutional care of 
sick. 

$500,000,000 estimate for total cost of illness. 

$486,000,000 estimate for cost to all families. 

The first and last give only very partial costs. It would 
seem, then, that $500,000,000 v/ould be a very conservative 
estimate of the actual cost of illness care for the people of 
the United States each year. 

Adding together, finally, the capitalized earning power 
of the workers dying from preventable diseases and acci- 
dents each year, over a billion dollars, the annual idleness 
loss enforced by serious illness of over five hundred million 
dollars, and the cost of institutional and private care of 
the sick amounting to more than another five hundred mil- 
lion dollars and we have a total annual loss to this country 
and its people of over two billion dollars, certainly a sum 
of sufficient proportions to warrant the most serious con- 
sideration of public health measures by all citizens. 

In terms of direct or indirect illhealth losses (some 
form of taxation) it means for each family a loss con- 
siderably over a hundred dollars a year. (For eighteen 
million families, $111 each.) And this, in the Fight of 



26 SCHOOL HEALTH ADMINISTRATION 

the Nearing efficiency wage statistics, means about twenty 
per cent, or more, of the median family income. When 
a majority of a people, already near or below a satisfactory 
standard of living, are forced to throw away such a large 
proportion of their meager incomes and to render up so 
many victims to health ignorance we evidently have a 
national problem which should receive first attention and 
speedy solution everywhere. 

C. Losses Due to Minor Ailments, Physical Defects, 
Undue Fatigue, and Generally Lowered Efficiency 
The morbidity losses above computed are those of deaths 
and relatively acute and serious illnesses. These are all that 
curative medicine has to any considerable extent so far 
recognized. Modern and future preventive medicine will 
look more and more to incipient and beginning diseases. 
The vicious sequences, like undue fatigue, then "bad cold," 
then consumption, and finally death, are entirely too frequent 
for a schooled and civilized people. Different estimates 
by competent observers^® show that on the average for "well" 
persons from three to five days are lost each year because 
of such indispositions as indigestion, sick headache, tooth- 
ache, neurasthenia, and bad colds.*^^ That most of these 
are easily preventable losses a host of competent witnesses 
give assurance. Doctor Luther H. Gulick, for example, 
says that "something like nine-tenths of all the minor ail- 
ments that we have, and which constitute the chief source 
of decreasing our daily efficiency, could be removed by 
careful attention." And further, "With the removal of 
nine-tenths of our disabilities and the conservation and 
further development of our natural powers the average 
person can increase his efficiency lOO per cent, that is, 
he can be twice as effective. This does not refer to doing 
merely or mainly twice as much work, of course, but by 
making less mistakes, and by working at a higher degree 
of speed when he does his work." 

We shall not attempt to compute in financial terms 
these widespread losses of efficiency from minor ailments. 



NATIONAL HEALTH PROBLEM 27 

They constitute a large part of the general unnecessary- 
health losses of the nation. These great and serious 
problems of the nation are the first problems of 
its institutions. In the case of the health problem 
we have a universal need which, because of its foundation 
m ignorance, is peculiarly the problem of the public school, 
the fundamental agency of social improvement and reform. 
Legislative changes bringing to families pure water, light, 
air and foods, or better incomes and hours of labor, or 
better protection from disease germs — all these wait on the 
generation with more adequate health knowledge, health 
habits, and health responsiveness. Better health knowledge, 
better health habits, and greater sensitiveness to bad health 
conditions must come very largely with the children from the 
public schools. What the health problem means to the 
schools themselves let us now inquire. 

Complete references at end of Chapter Two. 



CHAPTER TWO 
THE SCHOOL HEALTH PROBLEM 

PREVENTABLE SCHOOL LOSSES^ VITAL AND ECONOMIC 

/. Death Losses 

The death losses of the boys and girls of the public 
schools, are, in the light of their preventability, appalling. 
The 1 9 10 Mortality Statistics show that in the registration 
area alone a total of about fifty thousand children, between 
the ages of five and nineteen inclusive, died during the 
year. Very few cities in the United States give separate 
statistics of the deaths of school children. Children elim- 
inated by death have received little more attention or study 
in the past than those retarded or eliminated by illness and 
other causes. So neither the Census Bureau nor the Bureau 
of Education have the facts. An approximate computation 
may, however, be made. 

In the age group, 5 to 9 years, in 19 10 there died in 
the registration area 17,943 children (2.2 per cent of all 
deaths) ; in the 10 to 14 years' group, 11,736 children died 
(1.5 per cent) ; and in the 15 to 19 years' group there was 
a death loss of 19,772, or 2.5 per cent of the total number 
of deaths of all ages. (I have been unable to get the 
number dying at each year of Hfe.) For the 5 to 14 years' 
group the total is approximately thirty thousand (29,679) ; 
and for the 5 to 19 years' group the total is about fifty thou- 
sand (49,451). Most school children will, of course, be 
found in the first group, 5 to 14, although many will be 
found in the second group because of the higher deathrate, 
and the number in secondary schools. 

38 



SCHOOL HEALTH PROBLEM 29 

Calculated as was the total number of deaths in the 
United States, we find that the deaths between the ages five 
and nineteen would be 6.2 per cent (sum of the above per- 
centages) of the total number of deaths in continental 
United States (1,600,000), or practically a hundred thou- 
sand (99,200), 

Not all these children were enrolled school children. 
Dr. G. D. Strayer's "Introductory Survey" to the 19 10 
report of the Commissioner of Education shows that in the 
school year, 1908-9, more than seventy (72.22) per cent 
of the children between the ages 5 and 18 inclusive were 
enrolled in the '"'"common schools." This does not, how- 
ever, take in the nineteen-year group included above, nor 
the private school enrollment. 

72.22 per cent of 99,200 is 71,642. Deducting very 
liberally for the nineteen-year group, by methods largely 
estimations, we should say that, at the very least, 65,000 
of the children enrolled in the public schools died during 
the calendar year. 

TABLE III. 
SHOWING THE PREVENTABILITY OP DEATHS OP CHILDREN OP ELEMEN- 
TARY SCHOOL AGE, 5-14, FOR 25 MOST NUMEROUS 
CAUSES OP DEATH, 1910 

No. deaths Per cent Total No. No. Pre- 

in regis- Pre- deaths ventable 

Causes of Deaths. tration area. ventable. in the U. S. deaths. 

1. Accidents 3,760 . . 6,300 .... 

2. Diphtheria and croup 3,638 70 6,200 4,340 

3. Scarlet fever 2,173 50 3,700 1,850 

4. Pneumonia 1,802 45 3,050 1,370 

5. Heart, organic disease 1,727 25 3,000 750 

6. Typhoid fever 1,537 85 2,600 2,210 

7. Tuberculosis of lungs 1,537 75 2,600 1,950 

8. Tuberculosis, other 1,519 75 2,560 1,920 

9. Appendicitis 1,218 50 2,160 1,080 

10. Meningitis 1,048 70 1,600 1,120 

11. Measles 740 40 1,250 500 

12. Rheumatism, articular 684 10 1,150 116 

13. Broncho-pneumonia 670 50 1,140 570 

14. Diarrhea and enteritis 601 60 1,020 612 

15. Brighfs disease, kidneys 487 40 820 328 

16. Endocarditis, heart 429 25 730 182 

17. Nephritis, acute, kidneys 418 30 700 210 

18. Spinal cord, others 410 . . 690 

19. Diabetes 350 10 500 60 

20. Tetanus, lockjaw 315 80 530 424 

21. Whooping cough 245 40 410 164 

22. Peritonitis 241 55 400 220 

23. Intestinal obstruction 215 25 390 97 

24. Epilepsy 197 . . 330 

25. Influenza, grippe 195 50 330 82 

26,227 67* 44,270** 20,155 

Total number of deaths, 5-14, in registration area, 29,679. 
Total number of deaths, 5-14, in the U. S., about 50,000. 
Total number deaths preventable, about 33,500. Based upon 1910 U. S. 
Mortality Statistics and Fisher's Preventability Tables. 

*Pisher's average. **Estimated. 



30 SCHOOL HEALTH ADMINISTRATION 

TABLE IV. 

SHOWING THE PREVENTABILITY OP DEATHS OP CHILDREN OF HIGH 

SCHOOL AGE, 15-19, FOR 25 MOST NUMEROUS CAUSES 

OF DEATH IN 1910. 

No. deaths . Per cent Total No. No. Pre- 

in regis- Pre- deaths veritable 

Causes of Deaths. tratlon area. veritable. in the U. S. deaths. 

1. Pulmonary Tuberculosis 5,166 75 8,650 6,487 

2. Accidents and undefined 2,525 .. 4,230 .... 

3. Typhoid Fever 1,681 85 2,830 2,405 

4. Heart Disease, Organic 1,158 25 1,940 485 

5. Pneumonia 1,140 45 1,920 864 

6. Tuberculosis, other parts 933 75 1,750 1,177 

7. Appendicitis 754 50 1,270 63r. 

8. Bright's Disease 440 40 740 296 

9. Suicide 326 . . 550 .... 

10. Meningitis 294 70 500 350 

11. Rheumatism, Articular 261 10 450 45 

12. Diabetes 258 10 450 45 

13. Scarlet Fever 232 50 400 200 

14. Diphtheria and Croup 228 70 400 280 

15. Nephritis, Acute 199 30 340 102 

16. Endocarditis (Heart) 196 25 340 85 

17. Epilepsy 172 . . 300 

18. Peritonitis 162 55 280 154 

19. Broncho-pneumonia 158 50 280 140 

20. Cancer and other tumors 152 . . 260 .... 

21. Spinal Cord, other Dis 130 .. 220 .... 

22. Influenza, Grippe 119 50 200 100 

23. Intestinal Obstruction 117 25 200 50 

24. Measles 112 40 190 76 

25. Apoplexy, Cerebro. Hem 103 35 180 63 

17,016 *67 28,780 14,039 

♦Fisher's average for all causes of death. 

Total number of Deaths, 15-19, in Registration Area, 19,772. 
Total number of Deaths, 15-19, in the U. S. about 34,000. 
Total number of Deaths, 15-19, Preventable, about 24,100. Based upon 1910 
U. S. Mortality Statistics and Fisher's Preventability Tables. 

PREVENTABILITY, AND ECONOMIC LOSS TO SCHOOLS FROM 
DEATHS OF SCHOOL CHILDREN 

Professor Fisher's ratio of preventability for childhood, 
with the median years 2 to 8, is 67 per cent. The percent- 
age for the children of school age would be considerably 
higher, not only because of the good means of social control 
but because of the greater bodily resistance and consequent 
fewer deaths in the school period as compared with those 
on either side, older or younger. Seventy per cent would 
probably be a very low estimate. Seventy per cent of 
65,000 is over forty-five thousand (45,500). A truer 
figure would probably be fifty thousand. For an entirely 
conservative number of preventable deaths of children en- 
rolled in the public schools (not counting private school 
children) of the United States, let us take forty thousand 
(40,000). This is the annual price we pay in the deaths 
of our school children for inadequate health measures. The 
two accompanying tables state the facts concretely. 



SCHOOL HEALTH PROBLEM 31 

That this is probably a very conservative number future 
statistics will show. Germany and Sweden have already 
cut down their death rate for the school ages even more 
than this.^^ 

MONEY LOSSES 

The biggest problem of the public schools is to get 
sufficient money to carry on their work. How much have 
the schools spent In educating these forty thousand children 
dying of preventable deaths in any one year? Multiplying 
the average per capita cost of public schools (enrollment 
basis) of about $23, by this number (23 times 40,000) 
we have for one year a wasted expenditure of $920,000, 
probably in all about a million dollars. The median num- 
ber of years that these children had been in school was 
probably five. This would make a total annual expenditure 
by society for which it received no return (in educating 
pupils who die during school age) amounting to about 
five million dollars. This sum is exceeded by the total 
annual 1909-10 school expenditures of only four cities In 
the United States. 

A statistical fallacy probably creeps in here similar to 
that evident In the calculated enormous economic losses 
due to retardation found so frequently In superintendents' 
reports and statistical studies.^^ The cost of one pupil 
one year, due to the economic law of diminishing expense, 
cannot rigidly be called the per capita expenditure, perhaps. 
But that there is a very large economic loss to a city through 
educating children who die before the age of productivity, 
and that a very large share of It is preventable Is In- 
disputable. 

//. Illness Losses 

A. THEIR EXTENT 

As In the case of actual deaths among pupils, very few 
school systems keep a separate record of absence due to 
illness, and so the actual effect of Illness absences as well as 
lowered pupil efficiency upon retardation and poor school 



32 SCHOOL HEALTH ADMINISTRATION 

work are unsolved problems. The amount of absence due 
to Illness is enormous and can partially be determined by 
the number of exclusions for contagious diseases, the num- 
ber of school children, both ill and well, quarantined dur- 
ing the school year, and the number absent voluntarily be- 
cause of illness as it may be recorded on the teachers' record 
books. That at least 50 per cent of such absence Is 
preventable can be judged from the ratio of preventabllity 
of deaths for childhood and the fact that much of this 
loss is due to minor ailments like toothaches and colds. 

The general absence from all causes can rather accur- 
ately be told. Dr. Strayer's statistics mentioned above^^ 
show that the "average number of days the schools were 
kept during the year" for all public schools in the United 
States was 155.3, while the "average number of days at- 
tendance by each pupil enrolled" was only 11 2.6. Although 
the difference of 43 days does not, for various reasons, ac- 
curately show the total average absence by pupils. It cer- 
tainly cannot be very far from at least 22 days absence 
each, an average attendance of 85 per cent. City schools 
alone have a longer school year and better attendance, of 
course. This number (22) applied to the total number of 
pupils enrolled in 1909-10, 17,506,175 (not counting the 
estimated 1,498,701 private school pupils) gives the total 
number of days lost in the public schools of the United States 
through absence, while enrolled, as nearly four hundred 
million (385,135.850)- 

The recent Sage Foundation Investigation entitled "A 
Comparative Study of Public School Systems In the Forty- 
eight States," page 13, shows an average absence ranging 
from 44.2 per cent In Mississippi to 12.2 per cent in Oregon. 
The question Is as to the amount due to illness. 

Farr's estimate, used by Fisher, of two persons con- 
stantly seriously ill for each annual death, applied to the 
sixty-five thousand deaths of school children would mean 
a daily-absence through serious illness of 135,000 days, or 
for the school year of 155 days, 20,925,000 days. This 



SCHOOL HEALTH PROBLEM 33 

estimate does not include absences for minor ailments or 
physical defects, 

THE KEYES' INVESTIGATION 

Dr. Keyes' study of the "Progress Through the Grades 
of City Schools" gives the average annual amount of 
absence incurred by 2,033 pupils In a school system (Hart- 
ford, Conn.) with good attendance, as ten days each, or 
20,330 days in all.^^ He further says that "this loss of 
time, under the general acceptance and rigid enforcement 
in the community of the laws requiring constant attendance 
and prohibiting child labor, is practically a measure of the 
amount of illness in all grades from two to eight inclusive.'* 
Applying this low average loss of ten days annually to the 
school children of the country, we have an illness loss of 
ten times eighteen million or 180,000,000 days, about nine 
times the estimate given above for serious illnesses. The 
attendance laws were probably very much better enforced 
in this city than is common, and fewer children were out 
for minor illnesses than is general. 

This would probably make the illness loss to the great 
common schools of the country something like two hundred 
million days annually. In terms of school years of 155.3 
days each this means a loss of schooling equal to consider- 
ably over a million school years, 1,290,000. This might 
be classed as wasted or ineffective expenditure at $23 a 
year. 

Many other relatively inaccurate methods of computing 
illness losses might be used. The need is for more accurate 
and more general records. We shall leave the matter with 
the probably conservative estimate of an average of two 
weeks (ten days) for each child in the public schools of 
the country. This is on the average about seven per cent 
of the time. When we remember how few days of school- 
ing in their lifetime most children get this largely prevent- 
able loss due to illness of from four to seven per cent stands 
forth in all its enormity. 



34 SCHOOL HEALTH ADMINISTRATION 

B. ILLNESS LOSS IN RETARDATION^ ELIMINATION AND NON- 
PROMOTION 
I. THE PROBLEM 

Since the classic studies of retardation by Thorndike,^^ 
Ayres^*', and Strayer^^ there has been a national agitation 
over this matter. Our mass education has made necessary 
a large amount of repeating of grades. Children who have 
not been able to keep up with the large classes have been 
left behind, to do the half or whole year's work again. 
The number of such "repeaters" in any school system is 
large. For the United States as a whole, the number of 
children repeating grades each semester of the year, is 
astounding in size. The number of whole years repeated 
in any one year, equivalent to the same number of children 
repeating a whole year's work, must be considerably over 
a half million (600,000)^^ or about two or three pupils to 
a school room, the country over. Almost half of our pupils 
are above "normal age." 

Realizing the inaccuracy of all such figures at the present 
time let us raise also the problem of the effect of illness on 
retardation. There are at least three ways in which this 
retarding effect from illness Is felt: the retarding influence 
of absence, especially long absence due to a contagious 
disease, for the children ill, the retarding effect on those 
quarantined or otherwise kept out of school by other school 
children's quarantine (those In the same house or family), 
and, third, the effect of lowered physical vitality due to 
illness. 

A few school superintendents have said privately that 
pupils absent from illness '''grom while they are out and 
generally make up their work when they get back to school." 
Dr. Keyes' study of the actual, yearly. Individual records 
of a great many children does not bear out this opinion. 
He shows (page 54) that pupils losing more time than 
normal pupils have also more arrests; and lose very much 
more time on the average than accelerates or honor pupils. 
The average annual loss in days for 683 arrests was 12.3 
days; for 606 normals 10.2 days; for 613 accelerates still 



SCHOOL HEALTH PROBLEM 35 

less, 9.7 days; and for 131 honor pupils 6.8 days, about 
half the first sum. 

For the longer absences (considered as practically all 
due to illness) we have the same showing. The per cent 
of children losing four weeks or more in some one year 
is: For arrests, 76.6 per cent; for normals, 68.4 per cent; 
for accelerates 66.6 per cent; and for honors, 45.3 per 
cent. 

In table 28, Dr. Keyes shows the surprisingly close 
relationship existing between the number of days school- 
ing lost and the per cent of arrests during the year of loss. 
The number of days lost increase as follows: o, 5, 10, 15, 
20, 25, 30, 35, 40, 45, 50 or more, and the corresponding 
percentage of arrests in the year of loss increases con- 
comitantly, as follows: 14, 15, 17, 23, 40, 48, 47, 48, 
51, 48, 72. This is a correlation of about ninety per cent. 

According to this detailed study of the individual, cumu- 
lative record cards of pupils, at least twenty-five per cent 
of all pupils are retarded when they are absent for any 
length of time less than a month. Absences varying from 
one to two months stay the progress of fifty per cent of 
the absentees; and when the loss amounts to fifty days or 
more, as in the cases of serious illness or long quarantine, 
nearly seventy-five per cent of all pupils sustaining such ab- 
sence fail of promotion. 

2. DR. BACHMAN's study OF THE RELATION OF ABSENCE 
TO NON-PROMOTION 

In his investigation entitled "Report Upon Promotion, 
Non-Promotion and Part Time" as a part of the recent 
New York City school inquiry, and distributed about the 
first of March, 19 13, Dr. Frank P. Bachman gives the 
methods and results (pages 63-70) of an attempt to dis- 
cover the relation of absence from school to non-promotion 
among 568,612 elementary school pupils for the second 
term, February to June, 19 11. Unfortunately, late entrance 
to the schools, which is frequent in a city with a large 
floating population like this, could not, from the data col- 



36 SCHOOL HEALTH ADMINISTRATION 

lected, be separated from irregularity of attendance. The 
effect of such late entrance can be estimated from the data 
given later for Boston, where 650 of the 8,496 cases of 
non-promotion, or nearly 8 per cent, were judged to be due 
to this factor alone. 

"Of the 568,612 pupils on register in regular classes 
June 30, 191 1," he says, "382,406, or 67.25 per cent, were 
absent during the February- June term, 191 1, ten days and 
less; 97,512, or 17.15 per cent, eleven to twenty days; 
39,391, or 6.93 per cent, twenty-one to thirty days; 19,297, 
OJ* 3-39 P^i* cent, thirty-one to forty days; and 30,006, or 
5.28 per cent, forty-one days and above." (Italics mine and 
used only to distinguish.) 

The following tables are well worth study, but cannot 
be given here. A very large part of the absence is in the 
first half of the first grade, especially for long absences. 
The children of the upper grades have more short absences 
and very much less long absences. 60.27 per cent of the 
one A grade were absent twenty days and less in this half 
year and the percentage gradually rises up to the highest, 
eight B grade, where it is 95.17. The average is 84.4 
per cent for all grades. But for the long absences of 21 
days or more, there were 39.73 per cent of the lowest 
grade and only 4.83 per cent of the highest, with an average 
of 15.6 per cent for all grades. The first and second grades 
have a very large amount of long absence, while the seventh 
and eighth have comparatively very little, the averages be- 
ing 23.42 per cent and 8.21 per cent. 

What has all this varying and extensive absence for one 
term to do with the rate of school progress, economy of 
time, retardation and non-promotion? Dr. Bachman con- 
cludes : "Absence is a very large factor in increasing the 
number of non-promotions, and hence in increasing con- 
gestion. With the exception of the lA grade, absence 
affected more seriously the rate of promotion in the higher 
than in the lower grades; and, in all grades, the rate of 
promotion varies inversely with the amount of absence." 
(Page 70.) 



SCHOOL HEALTH PROBLEM 37 

The average rate of promotion for pupils absent 20 
days and less he finds was 92.03 per cent; for those absent 
more than 20 days the rate was only 70.57 per cent; a 
difference of 21.46 per cent. 

Dr. Bachman does not work out the chances of failure 
in different grades for the varying amounts of absence, but 
a good deal of light is thrown on the problem; and his dif- 
ferences by grades in rates of promotion for those above 
20 and those below 21, and his table showing the "Per Cent 
of Decrease in Non-Promotions at Rate of Promotion for 
Pupils Absent From Zero to Ten Days" (an average of 
64.3 per cent) are good substitutes. 

All these amounts of absence should be multiplied by 
two to approximate the annual loss in days for this city 
that year. 

We see here that there is a close correlation of amount 
of absence with the chances of non-promotion, and so of 
retardation. All we should need to do would be to find 
this numerically for grades and amounts of time lost, and 
then the part which ill-health played in causing this absence, 
in order to isolate and define the force of this health factor. 
Other factors than absence enter in, of course, but it will 
not be an impossible problem to compute for a given system 
or for many what the chances are that a child in a given 
grade has to pass for various amounts of absence from 
school. 

3. THE TEACHERS-REPORTS METHOD 

Another method of investigating the causal relationship 
between illness and retardation is to have teachers state the 
cause of each case of failure of promotion. A number of 
school superintendents have used this method in the last 
two years. Great care must be taken in using it, for the 
judgments of teachers frequently are wrong in these mat- 
ters and plurality and composition of causes come in to 
complicate the question. However, they do point toward 
the relative force of different retarding factors. 

THE HOBOKEN STUDY 

Superintendent A. J. Demarest, of Hoboken, found that 



38 SCHOOL HEALTH ADMINISTRATION 

19 per cent of the pupils of the schools had failed of pro- 
motion in February, 191 1. A study of the probable causes 

of 1706 of these failures gave the following: 

Pupils 

1. Irregular attendance; sickness one of the causes.. 297 

2. Quarantine of pupils 14 

3. Personal illness 65 

4. Poor school work by pupils and teachers, transfers, 

substitutes, etc 1,066 

5. Foreigners, and ignorance of the English language 100 

6. Late entrance into school for various reasons 91 

7. Truancy 3 

8. Physical defects: nervous troubles, adenoids, 

tonsils, vision, etc 28 

9. Early entrance, too young for school work 19 

10. Sluggish mentality and mental defects 23 

Total 1,706 

Personal illness alone (2 and 3) seems to account for 
less than five per cent of the cases of retardation. We 
should, however, have to pick out from the first, fourth, 
sixth and tenth groups those others whom illness quite 
largely made fail. This would raise the percentage prob- 
ably to 10 per cent. 

THE BOSTON NON-PROMOTION STUDY 

Boson made a study of this serious problem for the 
pupils failing of promotion for the half year ending June, 
1910 (School Document 14, 1910, page 26). "The sum- 
mary of these returns, which follows, is of great interest as 
revealing the real causes for retardation based upon an 
actual and individual investigation of a large number of 
cases for a definite and specific period." This judgment of 
the school committee is, of course, unsound, for a number 
of serious causes of non-promotion, and so of retardation, 
are not here listed. It would be very interesting, indeed, 
to take up just one other cause of non-promotion along 
health lines. What effect has the absence of teachers due 
to illness (not their inefficiency, but the relative inefficiency 



SCHOOL HEALTH PROBLEM 39 

of the substitutes and changes Incident thereto) have upon 
the amount of non-promotion? The amount of such ab- 
sence among women teachers of most school systems is 
enormous and easily ascertained. In general, does the num- 
ber of failures of the children increase with the amount of 
absence of their teachers? 

"In June, 19 10, the total registration in the elementary 
grades was 809,908. Out of this number, 10.5 per cent 
(8,496) were retarded, i.e., not permitted to progress to 
the next grade on the opening of school in September, 19 10. 
A blank form was sent to each principal requesting him 
to state the reason why each child in this group (8,496) 
had not been promoted. The following is a summary of 
the replies received: 
Illness (diphtheria, scarlet fever, measles, surgery, etc.). 1,25 2 

Mentally deficient 369 

Defective vision 241 

Defective hearing 83 

Defective speech 53 

Deformities 31 

Adenoids 13 

Nervous 7 



Total 2,049 

Mentally Immature (slow mental development) 2,803 

Entered late In the school year 650 

Lazy . 538 

Inattentive 495 

Absence caused by truancy, neglect, home work 468 

Came from other schools 405 

Came recently from foreign countries 331 

Promoted on trial at beginning of year 239 

Causes unknown 196 

Repeated change of schools 181 

Miscellaneous 127 

Cigarette smokers 14 

Total 8,496 



40 SCHOOL HEALTH ADMINISTRATION 

No account is taken here of plurality or composition 
of causes and it seems remarkable that teachers could say 
so definitely that just one thing caused a pupil's failure 
of promotion, when undoubtedly in perhaps a majority of 
cases several causes contributed to the failures. As we have 
arranged the items of the table, the first eight items are 
clearly within the scope of medical inspection, with the pos- 
sible exception of "mentally deficient." Until separate 
divisions of psychology are formed, however, and then only 
in very large school systems, we have the item rightly 
placed. Cigarette smokers are reported by many nurses 
as a part of their regular duties and a number of other items 
not among the eight were more or less matters of ill-health 
and physical defects but could not be ascertained by the 
teachers. The large nursing staff of the schools was set 
to work to improve the health conditions of these delayed 
children, with what results I have not learned. 

These eight reported causes applied to 2,049 children 
of the 8,496. This is nearly twenty-five per cent (25%). 
Bringing in the other health factors in other items of the list, 
we should probably have much over 30 per cent. 

If we were to take the judgments of the teachers and 
principals of the elementary schools of Boston at their 
face value, we should have to say that over one-fourth of 
all retardation in the elementary schools is due to some form 
of ill-health. But much of this was undoubtedly due to the 
inefficiency of the teachers and their substitutes, to a poorly 
adapted curriculum, to lack of proper administrative 
measures for getting pupils to school and inciting their max- 
imum efforts, to bad home conditions preventing opportunity 
for study, to lack of ventilation and adequate play and 
energizing facilities, etc., etc. However, it does show that 
in the opinion of these persons, and what is undoubtedly 
true, ill-health, physical defects, deformities, lowered vital 
efficiency, and the like, do have a serious retarding influence 
and prevent efficient economy of time in education. 

THE MT. VERNON STUDY 

Supt. Edwin C. Broome, of Mt. Vernon, N. Y., in his 



SCHOOL HEALTH PROBLEM 41 

191 1 report, pages 35-38, gives the results of a study made 
with the help of principals and teachers of the causes of 
the non-promotion of 562 pupils in June, 191 1. The teach- 
ers were asked to give the probable causes of the failure 
of their pupils. They did not, of course, list poor teaching 
as a cause; neither did they mention the absences of teach- 
ers, when pupils were in the not too-efficient hands of 
substitutes. There were 707 causes given for the non- 
promotion of 562 pupils that term, so more than one cause 
was given for several pupils. The table is as follows: 

Reasons assigned Cases 

1. Irregular attendance or late entrance to 

class 158 — 22.3% 

2. Lack of physical vitality 18 — 2.5% 

3. Mental dullness 133 — 19.0% 

4. Mentally deficient, or abnormal 30 — 4.2% 

5. Physical defects 14 — 2.0% 

6. Immaturity (applies to lowest grades) . . 96 — i3-4% 

7. Below grade, or conditioned, at entrance 

to class 125 — 17.7% 

8. Inability to use English 28 — 3-i% 

9. Inattention, carelessness, indolence 83 — i3-3% 

10. Miscellaneous 22 — 2.5% 

Total 707 — 100 % 

We can only guess at the amount of the irregular at- 
tendance which was due to illness, quarantine, exclusion by 
doctors and nurses, and the like. Absence is a big causal 
factor and illness is a factor lying back of much of this. 
A large part of the first five items would come under the 
head of bad health conditions. The smallness of the phy- 
sical defects item may well be questioned because the city 
did not have physical examinations of the pupils adequately 
to locate the defects, only inspection. A large number of 
cases of inattention, carelessness and indolence may have 
been due to such undiscovered defects. If we could say 
that probably at least 50 children were retarded because of 
illness alone this term, we should have a proportion of 
nearly ten per cent. This can be only an estimate, of course. 



42 SCHOOL HEALTH ADMINISTRATION 

THE TRENTON STUDY 

Superintendent Ebenezer Mackey, of Trenton, N. J., In 
his 191 1 report, shows, first, the causes of elimination from 
school, second, of non-promotion, and, third, of retardation, 
according to this method. Of 2,218 pupils who left school 
and did not return ("eliminated"), the following causes 
come within our perview: 

CAUSES OF ELIMINATIONS 

Withdrew because of poor health 192, or 8.7% 

Withdrew because of sickness in the family 33, or 1.5% 

Withdrew because of physical defects 9, or .4% 

Withdrew because of death 22, or 1.0% 



11.6% 

CAUSES OF NON-PROMOTIONS 

There were 8,394 pupils promoted during the year and 
1,943 not promoted, 1,055 of whom are called repeaters. 
1,918 causes are given for these 1,055 repeaters. The fol- 
lowing are the causes which concern us here : 

1. Ill-health 122, or 6.3% of the causes 

2. Physical defects 68, or 3.5% of the causes 

3. Dull 369, or 19.3% of the causes 

4. Irregular attendance 340, or 17.7% of the causes 

5. Absent at time of promotion. 109, or 5.6% of the causes 

6. Immaturity (mostly in the 

first 3 years) 133, or 6.8% of the causes 

These six of the twenty-one causes given are either 
directly connected with ill-health or should be studied 
further from the health standpoint. Undoubtedly back of 
several of these factors ill-health stands out in some way 
as a determining cause. There were physical examinations 
made of most of the elementary children in this city, so the 
percentage for physical defects must be based upon more 
definite knowledge than in Mt. Vernon, where they made 
up less than two per cent of the causes given. If teachers 
had more accurate knowledge of the health conditions of 
their children this factor would probably be raised. As 



SCHOOL HEALTH PROBLEM 43 

it is, ill-health makes up 6.3 per cent of the factors given. 
Further analysis would probably show that ill-health alone 
was the cause in about 8 or 10 per cent of the cases. We 
need further studies along these lines. 

Besides studying elimination and non-promotion Super- 
intendent Mackey gives, third, the causes of retardation, 
i.e., of all the pupils who are below the grades they should 
normally be in at their respective ages. For 4,184 pupils 
in the elementary schools who were above normal age for 
their grades, the following excuses or reasons, among ten 
given, are offered, page 93 (3,682 mentions of the 10 
causes) : 

1. Sickness 257, or 7.0% of the causes 

2. Physical defects 2 19, or 6.0% of the causes 

3. Irregular attendance 550, or 15.0% of the causes 

4. Lack of ability 406, or 11.1% of the causes 

5. Lack of application 453, or 12.3% of the causes 

All of the last three mentioned causes may refer to 
pupils many of whom have an ill-health basis for their poor 
attendance, ability or application. Sickness is at about 
the same percentage as previously given. 

Data from many other cities might be offered. For want 
of space and time, and because of their relative inaccuracy, 
we must be content with these few. Until we have more 
careful health records of children, we can only guess at the 
influence of illness on school progress. 

4. GATHERING-THE-FACTS METHOD 

Another method used by superintendents of schools 
eliminates personal judgments quite largely, but still leaves 
the difficulty of separating combinations of causes. 

THE SOUTH MANCHESTER STUDY 

Superintendent F. A. Verplanck, of South Manchester, 
Conn., in his 191 1 report (see also 19 12 report, pages 12 
to 17) gives the results of a study of elimination and non- 
promotion, based upon the records of the pupils kept by 
the schools. Of 188 pupils eliminated from the schools, 



44 SCHOOL HEALTH ADMINISTRATION 

ill-health and death were the causes of 17 and 4 respectively, 
together making a percentage of 11.2 per cent. 

Two hundred forty-one pupils, or 17.4%, were not pro- 
moted. Of this he writes : "I am confident that the figures 
would have been still better had it not been for the pre- 
valence of contagious disease, which seriously Interfered 
with the attendance." 

The attendance factor is shown by comparing the aver- 
age number of days attended by those promoted and those 
not promoted. The schools were In session 186 days, and 
the promoted pupils lost on the average 32 days, while the 
non-promoted pupils lost 52 days, a difference of four 
weeks, a month in favor of the promoted pupils. A very 
large part of this low attendance of all was due to the 
epidemics of diphtheria, scarlet fever, and measles, and 
other forms of illness. How much we cannot say. 

The physical defects causes given in the report will be 
offered under that heading later. 

ATTENDANCE OFFICERS^ REPORTS 

Another way to get at the amount of absence due to 
ill-health Is through the reports of attendance officers, given 
in many superintendents' reports, but in only a few adequately 
analyzing the causes of non-attendance. In South Man- 
chester, 755 absentees were looked up, with the following 
results of interest to us here: 

Causes of Absences from School, for 755 Pupils. 

Personal illness 305, or 40.4% 

Illness in the family 57, or 7.8% 



362, or 48.0^ 
- Here we have a proportion of almost 50 per cent due, 
according to the officer's statement, to ill-health. We have 
shown that there is a close correlation between absence and 
failure of promotion. What percentage of the cases of 
non-promotion in South Manchester were due to the vari- 
ous ill-health factors such as exclusions by medical officers, 
quarantine of pupils 111 and only exposed, actual personal 



SCHOOL HEALTH PROBLEM 45 

illness, and illness in the family which makes necessary 
an older child's help at home or the younger ones to stay 
at home "because mother was sick and could not get them 
ready," we cannot say. The writer's personal judgment 
based upon the tables given and other factors in the situa- 
tion places it at nearly 20 per cent of the non-promoted 
pupils. There was probably, however, an abnormally large 
amount of infectious disease in this city during the year. 

- THE SCHENECTADY TABLE 

In the Schenectady report for 191 1 Superintendent A. 
R. Brubacher gives a table, page ^3^ which potentially might 
throw some light on this problem. Unfortunately only facts 
for unpromoted pupils are given, without a control class, 
or the possibility of comparing the data with promoted 
pupils, so we can draw no satisfactory conclusions. The 
total registration was 11,074, of whom 385 failed outright 
and 263 failed on condition, 648 in all. 

For these pupils, all in the elementary schools, we are 
given the following facts: 

Defective sight 58 

Defective hearing 43 

Absences : 

Because of sickness 457 

Because of quarantine 34 

Unexcused 99 

Absence of 20 or more days 113 

These facts are interesting here, but to derive from them 
any conclusions we should have to have the six items of 
data for at least the number of: 

Pupils promoted unconditionally. 
Pupils failing, with a condition. 
Pupils failing unconditionally. 
To which might well be added the same data for 

Pupils promoted, but with a condition. 
It is probably true that these figures show abnormal con- 
ditions for retarded children in the direction of ill-health. 
It is significant that 113 of the 648 pupils were absent a 



46 SCHOOL HEALTH ADMINISTRATION 

month or more (whether of one of the two groups or 
the other, or of both, and In what proportions, we do not 
know), which, according to Keyes, would tend to fail over 
50 per cent of the number. 

5. QUARANTINE ABSENCE AND RETARDATION 

Another way of studying the effect of ill-health is to take 
the children who have been quarantined and see what their 
chances of promotion are in comparison with other chil- 
dren. No person has yet attempted such a study so far 
as the writer is aware. 

Absence due to quarantine is given in a number of cities. 
Newark in the 19 11 report furnishes the following strik- 
ing data: 

Absence due to quarantine 56,517 days 

Total absence due to all causes 1,055,560 days 

Total attendance of all pupils 8,890,974 days 

Here we see that the attendance is only eight or nine 
times the amount of absence, and that quarantine absence 
makes up over 5.3 per cent of the total amount of absence. 
The average length of quarantine for 1,892 pupils given 
separate mention was over 21 days each. 

If statistics were gathered regarding these quarantined 
pupils in any city and their promotions much light could 
easily be thrown on the problem. 

6. EXCLUSION ABSENCE AND RETARDATION 

Many pupils are excluded by physicians and nurses who 
are not quarantined. The number of days lost is frequently 
reported. Thus in Philadelphia the exclusions for different 
ailments caused an average loss ranging from favus with 
60 days, or 12 school weeks, and chorea with an average 
loss of 57 days, over 11 weeks, down to exclusions for lack 
of cleanliness of one day and pediculosis with an average 
of three days. The average loss for each ailment was 
(1910 report of Board of Health) 17 days, or over three 
weeks. 

In the Hoboken 19 11 report we find that 383 pupils 
lost by exclusions 4105 days, an average of nearly 11 



SCHOOL HEALTH PROBLEM 47 

days, or over two weeks, each. We cannot obtain the medi- 
an, but we see how serious exclusions are. 

These figures show not only what a great factor In ab- 
sence Ill-health Is, but point out new fields for the investiga- 
tion of this serious problem of health In the schools and 
homes. 

NEED OF RIGOROUS INDUCTIVE METHODS 

Each of these problems must be solved through Inten- 
sive and extensive investigation and by persons skilled In 
inductive thinking and the technique of discovery in educa- 
tional fields. There are very many difficulties and pitfalls 
of which the general administrator or Investigator Is un- 
aware. It may happen, for example, that the Illness ab- 
sentees are a selected group who became ill because of 
general hereditary or sociological causes, and that these, not 
so much the absence, are the cause of poor school work. 
Practically all the fallacies of inductive thinking lie before 
each one who adds to the science of education, and the 
school health problem seems to be peculiarly Infested with 
them. 

SUMMARY FOR ILLNESS LOSSES 

In summing up the case for illness we can give a general 
quantitative statement of Its effect upon elimination, non- 
promotion and retardation in only the most hypothetical 
way. Our purpose has been accomplished if the tremend- 
ous Importance of this source of waste in education has 
been adequately emphasized, and the necessity for serious, 
technical Investigations of Its causes and prevention in each 
school system has been shown desirable. 

Such study will probably show that Illness In one form 
or another, directly or indirectly, but not Including physical 
defects, is responsible, as a single factor, for nearly twenty, 
five per cent of absences from school, for ten to fifteen 
per cent of the elimination, for ten to twelve per cent of 
non-promotion, each term, and for at least ten per cent of 
retardation. 



48 SCHOOL HEALTH ADMINISTRATION 

///. School Losses Due to Physical Defects, and Lowered 
Vital Efficiency 

A little more study has been made of the effects of 
physical defects upon school progress. Dr. L. P. Ayres 
summarizes these in the 19 13 edition of his book on "The 
Medical Inspection of Schools," Chapter II. In his book 
on "Laggards in Our Schools," Dr. Ayres develops statistic- 
ally the conclusion that "in general children suffering from 
physical defects are found to make 8,8 per cent less progress 
than do children having no physical defects." 

Serious strictures are made by Dr. W. S. Cornell in 
his book on "Health and Medical Inspection of School 
Children," pages 387 to 391, on the Ayres' findings, and 
by the writer in a later chapter, enough, perhaps, entirely 
to invalidate the quantitative conclusions; but of one thing 
we are sure, that physical defects do have a serious influ- 
ence upon school efficiency and school progress, exactly how 
much we can, at present, only estimate. 

DR. WALLIN^S STUDY 

A very technical study by Prof. J. E. W. Wallin, on the 
relation of oral hygiene to mentality, reinforces to some 
extent these conclusions. A squad of 27 school children in 
Cleveland, O., were given free dental treatment and hygienic 
instruction — filling of cavities, cleaning of gums, instruc- 
tion In the care of teeth, "fletcherizing" of food, etc. — 
and before, during, and from three to five months after 
this treatment were given a series of five mental tests to 
determine whether or not the remedy of these physical 
defects had produced a corresponding increase in mental 
power. 

"In spite of much individual variation, the results showed 
a decided gain in every test. The best proof of the benefit, 
and therefore of the importance of the work, is that, al- 
though all the members of the squad were laggards of from 
one to four years, only one failed of promotion in the term 
immediately following the treatment. The beneficial effect 
on general health of the children was noticeable to chil- 



SCHOOL HEALTH PROBLEM 49 

dren, parents, and teachers alike." {Dental Cosmos for 
April and May, 19 12. Article on "Experimental Oral 
Euthenics.") 

The conclusiveness of this elaborate investigation is lost, 
however, because no control squad of pupils was used. If 
another like class had been given the same treatment with 
the single exception of the oral hygiene treatment and in- 
struction and real differences found, we might suspect the 
truth of the conclusion that there is such causal relationship. 
We may reasonably suppose, however, that had any group 
of retardates such as these been selected and given special 
attention reaching into the homes with the help of nurses, 
with money rewards, with special testing by principal and 
physician, and with a small class for the teacher — had any 
similar class been given all this attention with no attention 
to mouth hygiene, or with the emphasis on some other 
factor, say deep breathing, or removal of enlarged tonsils 
and adenoids, or open-window classroom, or personal 
courtesy even, nearly, if not quite, the same results might 
have been obtained. That "during the experimental year 
only one of the 27 pupils failed of promotion," is not sur- 
prising, regardless of the oral hygiene. Pragmatically, such 
findings do good in getting a proper emphasis on certain 
features of health provision by school officials and others. 
How much is fact, and how much is the fallacies of plur- 
ality and composition of causes no one knows. We may 
demonstrate that "on the whole . . . the average child 
improved about 50 per cent in all the tests during the ex- 
perimental year," but, as the writer points out, there was 
a "paramount need of testing such a parallel group," and 
"our knowledge in this field is largely pretense, sham, 
illusion." 

superintendents' methods 

Another method of getting an idea of the effect of phy- 
sical defects on school progress and elimination is the 
teacher-report and studying-the-facts methods described 
above under illness effects. Looking back over these and a 



50 SCHOOL HEALTH ADMINISTRATION 

number of other such studies we can draw the following 
very tentative hypotheses: 

Physical defects are probably causal factors in about the 
following proportions among other causes: 

Five per cent of eliminations from school; 

Six per cent of non-promotion; 

Seven or more per cent of retardation. 
A pupil may, of course, miss promotion and still be 
young for his class, and, so, not retarded. It is the per- 
sistent "repeaters" who make up a large portion of the re- 
tarded. 

IV. Summary of Chapters One and Two 
The problems of life furnish the problems of education, 
and one of the most important of these is that of good 
health. No serious and extended attempt has previously 
been made by school officials to discover in a comprehensive 
manner the nature and the importance of this problem of 
the nation and of the schools. 

NATIONAL LOSSES 

The national health losses are those of preventable 
deaths, preventable serious illness, and preventable minor 
ailments and defects. 

Approximately 1,600,000 people in the United States 
die each year, or nearly two per cent of our population. 
Our most reliable computations, derived from life insur- 
ance records and health experts' estimates, indicate that 
probably 670,000 of these deaths, or 42 per cent, are 
reasonably preventable. Conservative and carefully cal- 
culated estimates of the national economic losses due to these 
preventable deaths indicate an annual loss of over a billion 
dollars. 

There are approximately three million persons seriously 
ill at all times in the United States. The chief national 
illness losses computable are those of lost wages and private 
and public care of the sick. These two forms of economic 
loss, very largely preventable, each amount to about five 
hundred million dollars annually. 



SCHOOL HEALTH PROBLEM 51 

Combined, we have a largely preventable economic loss 
in deaths and in Illness amounting to two billion dollars an- 
nually, a sum great enough to cover the land with preven- 
tive agencies. 

Added to these losses are those due to minor ailments, 
physical defects, and loiwered vital efficiency, largely pre- 
ventable. These ailments help to lower the working 
efficiency, cause much absence from daily employment, and 
are a serious source of expense to a large proportion of 
our population. Any study of the attendance of teachers 
in the schools, of workers in the factories and stores, or of 
day laborers, will point to enormous losses In these fields, 
decreasing national Wealth and increasing race degeneracy. 

SCHOOL LOSSES 

The principal school losses are in the form of deaths 
of school children, educated for a number of years and 
dying before the age of productivity, illness losses, and losses 
due to physical defects and lowered vital efficiency. Much 
can be done on this side of eugenics in eliminating these 
school losses. 

Nearly a hundred thousand children of school age die 
in this country each year. Strayer's government report 
makes possible an estimate of 65,000 deaths of enrolled 
public school children each year. No estimate is made for 
those In private schools, but the number is probably near 
five thousand. Fisher's estimate of preventability of the 
deaths of children makes possible an estimate of an annual 
unnecessary death loss of over 40,000 public school chil- 
dren. This is only part of the price we pay for inadequate 
health measures in home, school, community and nation. 
The socially ineffective school expenditures for the educa- 
tion of children who die before the age of productivity are 
enormous but, as yet, uncomputed. Generous health meas- 
ures In schools may well be justified on this basis alone. 

The illness losses to the schools are for both teachers 

and children, but only those for the latter are studied.* 

* Professor Terman has made an investigation of the former in a 
book entitled "The Teacher's Health," Houghton, Mifflin Co. 



52 SCHOOL HEALTH ADMINISTRATION 

These illness losses come in the form of economic losses 
to the school and in personal losses through elimination, 
non-promotion, retardation, and lowered vital and school 
efficiency. The chief outward result of school illness Is 
that of non-attendance, and the effect of such absence has 
been studied in a number of ways, several of which are 
given, but none of which are conclusive. Tentative sug- 
gestions are reached that illness is the chief or only factor 
in perhaps lo to 15 per cent of elimination from school, 
10 or 12 per cent of non-promotion each term, and at least 
10 per cent of retardation. Beyond this, many pupils do 
poor work and barely pass from term to term because of 
lowered vitality due to illness past or present. 

The school losses due to physical defects have also been 
problems of a number of investigations, but none of these 
arrives at a quantitative statement which warrants belief. 
The whole problem is open for investigation. That the 
losses are large and serious seems quite evident. Physical 
defects are probably the chief or only factors in about five 
per cent of the elimination from school, six per cent of 
non-promotion, and seven per cent of retardation. Careful 
studies will probably raise these tentative estimates, made 
here only for the purpose of emphasizing these health 
problems as an introduction to the later chapters. The 
lowered vital efficiency due to physical defects of the pupils 
who barely pass with very low standards from term to term 
must also be considered in this problem. 

Since illness and physical defects frequently go together, 
'their combination in any one pupil or pupils offers a very 
serious menace to school efficiency, probably causing, as 
combined factors, almost fifteen per cent of elimination, six- 
teen per cent of non-promotion, and seventeen per cent of 
retardation. When we consider the enormous proportion 
of the twenty million school children who fall into one or 
more of these classes, according to the best estimates, the 
school health problem stands out as one of the acute 
problems of modern life. 

The following chapters will attempt to show what 



SCHOOL HEALTH PROBLEM 53 

American cities are doing for the health of the children and 
the nation ; what twenty-five cities are doing in detail with 
critical consideration of their efforts; and, finally, what 
probably can be done in the administration of educational 
hygiene along more effective and economical lines. 



References 



1. Beyer, Popular Science Monthly, February, 1912. 

2. Ditman, "Education and its Economic Value in the Field of Pre- 

ventive Medicine," Columbia University Press. 

3. Fisher, "National Vitality" in Report of the National Conserva- 

tion Commission, Senate Document No. 676. 

4. Flexner, "Bulletin 4," Carnegie Foundation. 

5. Terman, "Professional Training for Child Hygiene," Popular Sci- 

ence Monthly, March, 1912. 

6. National Vitality, page 736. 

7. Durand, Census Bureau, 1910 Mortality Statistics. 

8. Bruere, in Harper's Magazine for April, 1912. 

9. Page 8, Mortality Statistics. 

10. Page 10, Mortality Statistics. 

11. Quoted in National Vitality, page 741. 

12. National Vitality, Chapters I and II. 

13. National Vitality, page 728. 

14. Annual Report. 

15. Journal of Outdoor Life, March, 1912. 

16. National Vitality, page 741. 

17. Popular Science Monthly, March, 1912. 

18. Biggs, National Vitality, page 741. 

19 and 20. National Vitality, Chapter III. 

21. Fisher, in private letter. 

22. Ayres, "Laggards in Our Schools," 1913 edition of "Medical In- 

spection of Schools," and bulletin on the Money Cost of Repeti- 
tion; and Elson, Cleveland, 1912 Report, and many other in- 
vestigators. 

23. Strayer, Bureau of Education bulletin No. 451. 

24. Keyes' Doctor's Dissertation, "Progress through the Grades of 

City Schools," Columbia University Contributions to Education. 

25. Bureau of Education bulletin No. 4, 1907, and articles in Psycho- 

logical Clinic, Jan. and Feb., 1910. 

26. Ayres, "Laggards in Our Schools." 

27. Strayer, Bureau of Education bulletin No. 451. 

28. Ditto. 



CHAPTER THREE 

HOW THE HEALTH PROBLEM IS BEING MET IN 
SCHOOLS AND NATION 

I. PUBLIC HEALTH PROVISIONS 

The emergence of the health problem as one of serious 
national importance Is of recent date. In these few open- 
ing years of the twentieth century the gradual Increase of 
health needs and health knowledge has flowered forth in 
what one writer terms "the renaissance of the physical 
conscience of the race,"^ after lying dormant since the time 
of Pericles. Why health has for so long been a matter of 
relative unconcern ; why a fatalistic attitude not only toward 
plagues, sweeping off millions of people,^ but toward sick- 
ness and high death-rates in general, has been maintained, 
is not easily explained. This attitude of the race In its 
long health-middle-ages, stands out, however. In remark- 
able contrast both to that of the Greeks, health as a religion, 
and that of the present, health as a science. The reverent 
teaching and practice of sound life and normal physical 
development in Athens; the ignorant asceticism and plagues 
of the later periods; and the discovery of the causes of 
disease and early death with the growing ideal of health 
as an individual and public duty — these are the three ages 
of Health. The great number of years does not adequately 
express the gaps existing betwteen the Olympic games with 
Hygieia; the Black Death with Simon Stylites; and the 
present when a German or American soldier Is punished for 
getting an Increasing number of diseases and Colonel Gorgas 
is scientifically overcoming death at Panama.^ 

Among the explanations must be, of course, the general 

54 



MEETING THE HEALTH PROBLEM 55 

causes of the dark ages; theologic asceticism; the poverty 
of the masses which made life cheap and perhaps most 
additions to the hving undesired; the tremendous general 
ignorance, especially of health mlatters; the open, relatively 
healthful life of an agricultural people; and the general 
individualistic form of life and government. The marvel- 
lously rapid change in public opinion and practice with 
regard to health matters is due quite largely to the in- 
dustrial revolution with its development of factory life, 
congested business cities, and dependent poverty; to the 
transformation of preventive and curative medicine and 
sanitation into relatively exact sciences; the growth of demo- 
cracy and the altruistic conscience ; the consequent rise of 
public health agencies;^ the better conditions for adequate 
social control of health and disease, especially in cities; the 
great increase of wealth in the hands of a few and the 
accompanying possibilities of health philanthropy (e.g., the 
Rockefeller Foundations, the Sage Bureau of Child Hy- 
giene, the Forsythe Dental Dispensary at Boston, and many 
other private health charities, educational, preventive and 
curative) ; the increase in the organs of public opinion and 
the increased attention of newspapers and magazines to 
public health instruction; and, finally, and fundamentally, 
the growth of the public school system in recent years with 
its unparalleled opportunity for health control of the 
younger generations and their education as to how to live 
healthily, happily, and efficiently in the modern world. 

DEVELOPMENT OF GENERAL HEALTH AGENCIES 

This universal health awakening in progressive nations 
can be admirably illustrated by the recent rise and rapid 
growth of public and private organizations for the promo- 
tion of more universal health, A plotted curve of such 
growth in its entirety would show little rise since the tim^es 
of Harvey and Jenner until about the third quarter of the 
past century, when it would rise abruptly and continuously 
and have a still sharper ascent in these opening years of 
the twentieth century. The first rapid rise shows, quite 
largely, the acquisition of health knowledge; the second the 



S6 SCHOOL HEALTH ADMINISTRATION 

increasing application of such knowledge. Public and per- 
sonal hygiene, in its practice, is yet several decades behind 
the health knowledge held by the few.^ President Butler's 
terse and accurate statement of the situation from the school 
point of view, well expresses general conditions: "It is 
not too much to say that health, its preservation and de- 
velopment, is all-controlling in present-day educational 
theory, although it is unfortunately far from being so in 
practice. The chief reason for this discrepancy between the 
ideal and the real is simple ignorance."^ 

To make private science public health knowledge and 
practice, is the mission of a great number of new agencies, 
often starting as private bodies and gradually becoming 
public institutions, according to a rather universal method 
of social evolution. Among such private bodies are: The 
International Congresses on School Hygiene beginning in 
1904 at Neuremberg; the American Medical Association; 
the health foundations endowed by Rockefeller, Sage, Car- 
negie and others; the Playground Association of America, 
beginning in 1907; social settlements and Christian associa- 
tions everywhere; the Congresses of Sanitary Engineers; 
the Committee of One Hundred on National Vitality; the 
National Associations for the Study and Prevention of 
Tuberculosis, for the Conservation of Vision, for Sanitary 
and Moral Prophylaxis, for the Study and Prevention of 
Infant Mortality, for the Study of the Feeble Minded; the 
National School Hygiene Association; the National Con- 
sumers League, the National Child Labor Committee, the 
New York and other bureaus of municipal research,^ the 
National Educational Association to same extent since 
1900; tenement house commissions, and various health 
magazines and general magazines with health articles and 
departments. These and a great many other organizations 
in this country and abroad are either directly or indirectly 
working for public health.* 



*G. Stanley Hall gives a list of ninety and more in his "Educational 
Problems," chapters XI and XII. 



MEETING THE HEALTH PROBLEM 57 

One of the most interesting developments has been the 
efforts of hfe insurance companies to Iceep down the death 
rate of their policyholders. Certain companies^ distribute 
free literature on various phases of the preservation of 
health, hire visiting nurses, and give free annual medical 
examinations to policyholders. The Lubin Vitagraph Com- 
pany has even dramatized the idea and is sending over 
the world films portraying an insurance president saving 
his company from paying a big death loss at a financial 
crisis by sending at some expense a bankrupt family South 
to restore the father's health, and brought to such an atti- 
tude by the naive request of the sick man's little boy : "We 
want the money to make father well now; we won't need 
it when he gets well." 

Some of the other public health movements and agencies 
are: the municipal, county and state Boards of Health with 
their rapidly enlarging scope and powers, the latter now 
more extensive than those of any other division of the public 
service not excepting the police; the Boards of Education, 
in response to the needs of the times, similarly widening 
their community service; the United States Department of 
Labor with Its mortality census bulletins from the Bureau 
of the Census and other health studies in the field of labor; 
the Department of Agriculture, working almost entirely In 
the past for the health of domestic animals rather than 
the people; the Bureau of Education, which has as yet con- 
tributed very little to public health; and the United States 
Public Health and Marine Hospital Bureau, and several 
others which, inevitably, will be united into one compre- 
hensive National Department of Health for the more 
organized and energetic development of health conditions 
in the entire country, similar to the work of the Depart- 
ment of Agriculture for the health of live-stock. 

There has recently been established also the Children's 
Bureau and placed in the Department of Labor. What is 
much needed Is a great increase In the scope and support 
of the Bureau of Education, corresponding somewhat with 
present-day needs and present-day ability in promoting 



58 SCHOOL HEALTH ADMINISTRATION 

child welfare. Following the rapid development of many 
private and public instrumentalities for health promotion, 
a correlating movement is setting in which will help to 
systematize and make more efficient the multitudinous scat- 
tered efforts. In America we have yet a long way to go 
in health provisions to equal the splendid work which Ger- 
many and Sweden have been doing for a number of years. 
(Dr. Irving Fisher says in a private letter: ^''Sweden, which 
has made the greatest progress in Hygiene of any country, 
is believed to have done so largely because of the medical 
investigations of its schools.") 

II. SCHOOL PROVISIONS FOR PUBLIC HEALTH 

While the health movement is but beginning in the schools 
very much has already been accomplished in this country 
and elsewhere. We shall not stop here to review the move- 
ment abroad as this has ably been done in a number of 
books and articles.^ It seems desirable to preface the 
special detailed investigation of what school systems are 
doing for public health in a limited number of cities, with 
a brief general statement of some of the more prominent 
features of this recent movement in the schools of our own 
country. 

This investigation began with a study of data gathered 
by the Child Hygiene Bureau of the Sage Foundation under 
the direction of Dr. Leonard P. Ayres in the fall of 19 lo. 
A number of investigations into this problem then beginning 
were thus correlated into one comprehensive investigation 
which would give a bird's-eye view of the field and the 
general aspects of the movement in the schools. The fol- 
lowing questionnaire was printed on a return postal card 
and sent to every superintendent in the country (1285 in 
all), and after a second request was made of a number, 
returns were received from 1038 graded school systems: 

Date 

Have you a system of medical inspection? 

Year work was begun 

Does system cover inspection for contagious diseases? 



MEETING THE HEALTH PROBLEM 59 

Are vision and hearing tests made by teachers? 
Are vision and hearing tests made by doctors? 
Is there full physical examination by doctors? 

Is medical inspection administered by Board of Health or Board of 
Education? 

Number of school doctors Annual salary • 

Number of school nurses Annual salar)' 

Have you dental inspection? Is it by dentists? 

Do elementary children have regular outdoor recesses? 

Are recesses given in all elementary grades? 

Hovir many schools are supplied vi^ith individual drinking cups? 

Hov\7 many schools have sanitary drinking fountains? 

Are moist cloths used for dusting? 

Are dust absorbing compounds used for sweeping? 

How many schools have vacuum cleaning outfits? 

How often are classroom windows washed? 

How often are classroom floors swept? 

How often are classroom floors washed? 

Are adjustable desks in general use? 

How often are they adjusted? 

Do pupils receive special instruction on alcohol and tobacco? 

Do pupils receive special instruction on tuberculosis? 

Do pupils receive special instruction on first aid to injured? 

Name 

Place 

The disadvantages of getting facts by such means Is well 
known and has been further discovered through visits by 
the writer to a number of the towns replying and checking 
up reports. Nevertheless, for a general view such as this 
and covering the entire country, it is the best that can 
be done in a short time and at reasonable expense; and 
probably gives a fairly correct general notion of the present 
status of the health movement in the schools. ^° Some of 
the main facts discovered by this investigation are here 
summarized: 

1. Of the 1038 cities reporting 443, or 43 per cent, had medical 
inspection of some kind. 

2. The very rapid growth of medical inspection since 1890 is shown 
by the following series, giving the number of cities having medi- 
cal inspection systems for each year (duplications where figures 
are not known or there were no additions) : i, i, i, i, 4, 4, 4, 5, 
8, 9, II, 17, 23, 28, 37. 55, 77, III, 167, 263, 400, 443. In 1900 
eleven cities had such inspection; in 1905 there were 55. The 
very rapid increase has been since then. Probably at this writing 



6o SCHOOL HEALTH ADMINISTRATION 

not far from half of the cities of the country are attempting 
this work. 

3. In 443 cities reporting on this item, 336 had the work admin- 
istered by Boards of Education and 106 by Boards of Health. 
Formerly this work was all done by the Boards of Health but 
by state law and municipal agitation the work is being trans- 
ferred to Boards of Education and given a larger educational 
purpose. Not only inspection for contagious diseases, but careful 
physical examinations once a year, follow-up work, treatment, 
prevention, and cure are being developed. 

4. 405, or 39 per cent, of the 443 cities, report inspection for con- 
tagious diseases. It is probably correct to say that practically 
all cities, however, look out for contagious diseases by inspection. 

5. "In no fewer than 552 cities vision and hearing tests are con- 
ducted by teachers, and in addition the work is carried on by 
doctors in 258 cities." The tendency is for this work, required 
by law in certain states, to go into the hands of the school nurses. 
As practically applied a single teacher in a school has generally 
made these tests. The nurse or physical training teacher saves 
the regular teacher's time by doing such work. 

6. Of the 443 cities reporting medical inspection systems 214, about 
half, have thorough examinations by doctors. The annual physi- 
cal examination of every child, teacher and janitor in the school 
system by specially trained nurses and doctors will probably soon 
become an integral part of all health work in the schools. Life 
insurance companies are now beginning to offer free medical 
examinations to save the lives of their policyholders. The State 
has a greater interest than any private group in the health of 
its people. 

7. The returns showed that there were 141 5 school physicians and 
415 school nurses employed. While both are sure to increase 
rapidly in numbers it is the opinion of the writer that the ratio 
of three to one will shift in the direction of one to three, because 
of the greater value of the nurse's work in getting cures. Doc- 
tors will probably make the more technical parts of the annual 
physical examination; nurses will assist in this and make inspec- 
tions and follow-up cases. An increasing number of cities have 
nurses without doctors. 

8. Decayed teeth is the great "people's disease" and are the source 
of perhaps most ailments. At least fifty per cent of school children 
suffer from this malady. Only 69 cities have dental inspection 
by dentists. The number is rapidly increasing, however, and free 
dental treatment is bound to become as common as free text-books 
and free schools once fought as "socialistic." 

9. Medical supervision of schools, like most other improvements 
and the very schools themselves, has grown quite largely out of 
private efforts. We, therefore, find 75 doctors and 21 nurses 
receiving no pay from the schools. From this the salaries increase 
to four thousand dollars for one physician and fifteen hundred 



MEETING THE HEALTH PROBLEM 6i 

dollars for two nurses. The median salary for nurses is about 
$70 a month and for doctors about $35. Of course, the nurse 
gives five to forty times as many hours a week as the physician 
in most cities. 

HYGIENE OF THE SCHOOL ROOM. 

10. Of the 1038 cities reporting 947 or about 91 per cent have out- 
door recesses. There is a bad tendency the other way in north- 
eastern United States. 

11. 264 or about 25 per cent of the cities are abolishing the common 
drinking cup in the schools by the use of individual cups, and 
in 785, or about 75 per cent, by the installation of sanitary drink- 
ing fountains. Cheap, durable, h}'gienic and easily workable types 
of such fountains are being developed and they will undoubtedly 
become as common as blackboards in our schools. 

12. In 643, or over 60 per cent, of the cities the old feather duster 
or dust creator, is being displaced by the damp cloth. Unfor- 
tunately the latter requires more effort and constant vigilance 
is needed to keep up the standard. 

13. 894, or about 90 per cent, of the cities reported the use of dust- 
absorbing compounds for sweeping. Scientific tests are much 
needed in this field. The writer has seen ten cent oil work better 
under scientific control than two-dollar oil, sold to unsuspecting 
but health loving school boards. 

14. Cleanliness is perhaps the greatest health virtue. Eleven cities 
report the daily! washing of school floors and the frequency 
ranges down to 51 cities reporting never. The latter attempt 
to clean the floors with oil, not an impossibility. Once a month 
to once in three months seems to be the most common frequency. 

15. The frequency of floor sweeping gives 813 cities reporting daily, 
70 once in three days, and 106 once in four days. From these 
it ranges off to one city reporting "once in two months." Daily 
sweeping when there are eighty or more little feet in and out 
of a single room all day seems to be none too often. 

16. The washing of windows varies from "weekly" to "never." The 
mode is near once in three months. 

17. 428 cities report the use of adjustable desks, about 41 per cent. 
They are adjusted very uniformly. One city reports a daily 
adjustment, 13 once a year. The modes seem to be "as needed" 
and once in five months, each term. 

18. As to instruction in hygiene, 95 per cent (982) of the cities 
report the teaching of the effects of alcohol and tobacco; 63 per 
cent (649) help the children to understand and to combat the 
great white plague of tuberculosis; and 57 per cent (592) give 
occasional lessons on first aid to the injured. 

Had we the same statistics in each case for ten years 
ago with which to compare each of these items, remarkable 
improvement would undoubtedly be shown along most lines. 



62 SCHOOL HEALTH ADMINISTRATION 

Any detailed and rigorous investigation of particular cities 
would show, however, very much yet to be accomplished 
before the schools are practicing existing health science. 

STATE LAWS RELATING TO MEDICAL INSPECTION 

Through state legislation, great advance in the work 
of medical inspection has recently been fostered. Other 
phases of educational hygiene have also been improved but 
we shall give here only the main facts regarding this newest 
phase of hygiene. 

According to Ayres,^^ the first state law on medical in- 
spection is credited to Connecticut (1899) ^^id provided for 
sight and hearing tests by teachers. New Jersey stands 
first for an all-round scheme of medical inspection in the 
law of 1903. This act was permissive, however. Massa- 
chusetts again stands at the head, as having the first com- 
pulsory medical inspection law, in 1906. No state has yet 
(19 13) a state supervisor of educational hygiene. 

Up to May, 19 II, seven states had mandatory laws; 
ten had permissive ones; and in two states and the District 
of Columbia "medical inspection is carried on under regula- 
tions promulgated by the boards of health and having the 
force of law." This legislation has nearly all come about 
in the last five years, an evidence of the very rapid growth 
of the movement, and likewise of the spread of public 
opinion in a democracy. Much of this legislation, like the 
Massachusetts law of 1906, will need to be amended many 
times as the movement grows. One prominent physician, 
for example, writes from a Massachusetts town, "We are 
compelled by law to employ a physician as medical inspector 
but we have experimentally proved the nurse-alone plan 
best." With such a physician for consultation it is quite 
probable that specially trained school nurses may do most 
of the work, and the law will need amending to cover this 
development if it is generally followed. 

From Dr. Ayres' pamphlet previously mentioned the 
following table giving the principal features of state laws 
and regulations providing for medical inspection has been 
taken, with the author's kind permission. The five states 



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63 



64 SCHOOL HEALTH ADMINISTRATION 

covered by the investigation set forth in the following 
chapter are placed at the head of the list for easy reference. 
The tendency toward mandatory legislation in this mat- 
ter is worth noticing, as is also the uniformity of opinion 
that the Board of Education should have charge of it. State 
supervision, encouragement, and correlation are bound to 
come not only for medical inspection, but for all five divi- 
sions of school health provisions. 

THE PLAYGROUND MOVEMENT 

Recent statistics^^ show the same forward movement of 
supervised playgrounds. There are at least 332 cities main- 
taining supervised playgrounds. The 257 cities reporting, 
employed during the year ending November i, 1911, 4132 
men and women exclusive of caretakers on 1,543 play- 
grounds, and expended for the work $2,736,506.16. 
Thirty-six cities employed 377 workers all the year round. 
In 39 of the 257 cities the playgrounds were administered 
by school boards. This movement, also, is only about five 
years old. 

III. CONCLUSIONS 

In preceding chapters we have attempted to learn the 
magnitude of the national and school health problem. This 
chapter is the by-product of an effort to determine how 
adequately the present national and school health agencies 
measure up to the health needs. Many agencies and move- 
ments have necessarily been omitted, such as the abolition 
of the common drinking cup in public places in so many 
states ;^^ but we must confess, that, after looking most of 
them over in the light of the magnitude, complexity, and 
national character of our health problem, the present 
agencies seem rather purile and seriously inadequate. We 
are still quite largely in the volunteer, private stage of health 
provision evolution. 

A great many good movements have been started in 
many parts of the country; several states and cities seem 
to be fairly conscious of how much of an effort should be 
made to stamp out their preventable deaths and lowered 



MEETING THE HEALTH PROBLEM 6s 

vital efficiency in school and out; the National Government 
seems near to the provision of a national health bureau or 
department; but on the whole the few fairly adequate 
state health laws, the few strong city or state health depart- 
ments, the few school systems to which we can point that 
seem to comprehend the seriousness of the school health 
problem and are meeting it adequately; all these simply 
show us that we have but started on the road toward school 
and national health and normal physical development. It 
is a pleasure and inspiration to live in an age of such change 
and transition towiard better things. 

The speed and accuracy with which we adjust ourselves 
to our health needs will undoubtedly depend very much upon 
how well we study our health problem, determining just 
where it lies in personal, community, state, or national con- 
ditions; how adequately we plaii to meet the need; and how 
scientifically we test the effect our newly devised instruments 
have upon the conditions we started to ameliorate. 

We shall not proceed far in our health provisions until, 
as Davenport and others have shown, we shall find that a 
great deal of our ill-health and physical defects are heredi- 
tary and that much is brought out or created by bad socio- 
logical conditions. The evolutionist, Wallace, asserts that 
our social system is "rotten from top to bottom," that it 
produces most of the evils which eugenists would alleviate, 
and that eugenic reform must wait on social reform. It 
will be the part of wisdom, I think, to combine both 
methods of conscious social evolution, hereditary and en- 
vironmental. 

While the general administrative and special technical 
phases of health provisions in communities and schools are 
frequently difficult and complex, yet the ends to be reached 
are not many, and comparatively few hygienic principles 
are involved, 

"When people have pure food, pure water, pure air, 
and are freed from the dust of houses, streets, and manu- 
facturing industries; when they have good light and abund- 
ant sunshine, sanitary houses, barns, and outbuildings; when 



66 SCHOOL HEALTH ADMINISTRATION 

they are protected from germ-carrying agencies, such as flies, 
mosquitoes, rats, mice, and all such pests; when they are 
protected from people who are carriers of disease germs, 
and taught how to disinfect their homes and communities; 
when they are taught to work and play, eat and sleep, dress 
and bathe, according to the laws of health; when they learn 
to care for their teeth and their eyes, the main problems 
of hygienic living will be solved and human life relieved 
of its greatest sources of suffering and disease." 
— Fletcher B. Dresslar, Ph.D., Specialist in School Hygiene 
for the United States Bureau of Education, in his in- 
troduction to bulletin 528, on The Fifteenth Interna- 
tional Congress on Hygiene and Demography. 

REFERENCES 

I. R, C. Newton, M.D., The Renaissance of the Physical Conscience 
Popular Science Monthly, 1909. 

2. Ditman, Education in Preventive Medicine, Columbia University 

Publications. 

3. See 1913 articles in Scribner's Magazine, and many other publica- 

tions. 

4. Robert Bruere's article in the March, 1912 number of Harper's 

Magazine. 

5. Ditman, above referred to. 

6. Quoted by Elkington, in his "Health in the School." 

7. Generally to be found listed in the Survey Magazine. 

8. Metropolitan, and a few others. Bulletins are furnished persons 

requesting them. 

9. Books by Stevens, Kelynack, Wood, Crowell, Hogarth, Dresslar, 

Burks, Gulick and Ayres and the magazines such as The Child, 
and the Pedagogical Seminary. 

10. Ayres, What American Cities are Doing for the Health of School 

Children, bulletin of the Sage Foundation, division of Child Hy- 
giene. 

11. Ayres, Medical Inspection Legislation, bulletin from above Founda- 

tion. 

12. The Playground Magazine, January, 1912, and later numbers. , 

13. Dresslar, "School Hygiene," Macmillan. 
Burks' "Health and the School," Appleton's. 

Davenport, "Heredity in Relation to Eugenics," Holt & Co. 
Wallace, "Social Environment and Moral Progress." 

OTHER REFERENCES USED 

A. Articles in English, French and German in the Transactions of the 
Second International Congress on School Hygiene. 



MEETING THE HEALTH PROBLEM 67 

B. The Annual Reports of the Chief Medical Officer of the Board 

of Education of England, London, England, 1909-1912. 

C. The recent volumes of the National Education Association which 

is devoting much attention to health matters and has even changed 
the name of one division from that of Child Study to that of 
Child Hygiene. The 1912 Report has about 30 articles, reports, 
etc. (173 pp.) devoted to various aspects of Educational Hygiene, 
a change from little above zero before 1900. 

D. Many of the flood of articles, reports, investigations, etc., appear- 

ing in current books and periodicals, entirely too numerous to 
mention. 

E. The very valuable and suggestive account of "Typical Health- 

Teaching Agencies of the United States," Chapter 12, Vol. i, of 
the 1912 Report of the Commissioner of Education, by Dr. 
F. B. Dresslar, Specialist in School Hygiene. 

F. Reports of the National School Hygiene Association. 



COMPULSORY EDUCATION AND 
CONTAGIOUS HEALTH 

"The human race will he a better race because 
of the lessons that have been taught us by the 
child having contagious disease, the - backward 
child, and the physically defective child. Be- 
cause of these lessons, the youth of the future 
will attend a school in which health will be con- 
tagious instead of disease, in zvhich the play- 
ground will be as important as the book, and 
where pure water, pure air, and abundant sun- 
shine will be rights, and not privileges. He 
will attend a school in which he will not have 
to be truant, tuberculous, delinquent, or defec- 
tive, to get the best and fullest measure of edu- 
cation." — Gulick and Ayres, in "Medical Inspec- 
tion of Schools." 



PART TWO 

HOW THE PROBLEM OF EDUCATIONAL HYGIENE IS 
BEING MET IN TWENTY-FIVE CITIES 



TEACHERS OF THE WHOLE CHILD 

"The teacher should be held to more rigid re- 
quirements in regard to hygiene. Every teacher 
should he something of a physician. Our indif- 
ference to the physical phase of education is sug- 
gested by the fact that today a teacher may have 
passed from the kindergarten and through the 
university and still not know how to prevent or 
cure a cold. Not to know something about the 
preservation of health, to say nothing of the 
detection of physical defects such as adenoids, 
enlarged tonsils, bad eyes, faulty heart, weak 
lungs, etc., is, on the part of the teacher, inex- 
cusable ignorance. A doctor of philosophy with 
a cold in the head suggests a humorous interpre- 
tation of the old doctrine that nature abhors a 
vacuum." — Howerth, in Education for May, 
1907. 



CHAPTER IV 
GENERAL PHASES OF HEALTH ADMINISTRATION 

A. The Investigation. 

I. THE PROBLEM 

Because of the tremendous sociological importance of 
the schools' health functions; because so little, comparatively, 
is known about what the schools are actually doing for 
health in a detailed way; and because cities, getting the 
social contagion of the health movement, are hastily copy- 
ing the work of other localities without definite standards 
for the newer health provisions in the schools, it was con- 
sidered desirable that personal visits be made to a large 
number of typical cities, and studies made of their admin- 
istration of educational hygiene, and especially of medical 
inspection. The problem is too vast for any complete 
description or evaluation of health provisions by one person 
in two or three years. Adequately to determine the health 
needs, and to describe and evaluate the work of educational 
hygiene in one city is an enormous, but much needed, task. 
Consequently, only the larger phases can be dealt with, and 
only one phase, medical inspection, can be dealt with in 
any detail. 

Some of the problems with which the investigation 
began are as follows: 

1. How much does it cost? 

2. What are the types of administration and their relative 
efficiency ? 

3. Is there better scientific management of medical supervision 
by Boards of Health or by Boards of Education? 

4. What effect has such work on the health of the children? 

5. What effect has it upon pupil-efficiency in the schools? 

6. What is the relative merit of school nurses and doctors? 

71 



72 SCHOOL HEALTH ADMINISTRATION 

7. What are found to be the principal ailments of school children, 
how may they be classified, and what is their relative frequency? 

8. What is the attitude of the public and the physicians to the 
enlargement of such work? 

9. Of all the ailments and defects found how many are actually 
treated and cured? 

10. How great is the need for free treatment, and how are the 
cities responding? 

11. How much preventive work is being done by the cities in the 
way of play and playgrounds, open air schools, better school ventilation, 
physical training, education of parents along health lines, school baths 
and swimming pools, investigations into the health condition of school 
children, and the like? 

These and many other questions, gradually reshaping 
themselves as the investigations went on, were prominent. 
Only a few can be satisfactorily answered. Our ignorance 
of school health is vast and profound. Educators have been 
engrossed largely with other matters. A partial list of the 
great host of unsolved problems in this field has been well 
set forth by Professor Lewis M. Terman in the March 
(1912) Popular Science Monthly. It is significant that there 
are but two or three chairs of educational hygiene in the 
universities of this country. 

2. THE DATA AND THE METHOD 

Those cities were selected for investigation which had 
both school doctors and nurses and were in the eastern 
part of the United States. They were located from the 
Russell Sage Foundation investigation previously men- 
tioned. There were about forty-five such cities that had both 
school doctors and nurses at or near the beginning of the 
school year 1910-11. After visiting most of these and 
several others (forty in all) fifteen were finally eliminated 
for one reason or another. New York City, Baltimore and 
Philadelphia because they were too vast to be typical; others 
because too little definite data could be discovered; others 
because the work had begun too late in the school year; 
and still others because either the nurse or physician was 
employed by private organizations; or the work had just 
changed over from the Board of Health into the hands of 
the Board of Education (e. g., Ithaca, N. Y.). 



THE TWENTY-FIVE CITIES 73 

At least one visit, a half day to a week in length, was 
made to each city, and as many as ten visits were made 
to certain nearby cities. The time of visiting was in the 
school years of 19 10- 11 and 1911-12 and the intervening 
summer when playground and other such work could be 
seen. Additional visits have been made in the school year 
of 19 1 2-13, A weak point of the investigation was the 
inadequate time for many cities, and the frequent inability 
to see the various health agencies in actual operation. 
Where medical inspection was administered by the Boards 
of Health these agencies were studied as well as the schools, 
and where several agencies carried on the work all were 
studied. Board of Health reports from all the cities have 
been used as well as the United States Mortality Statistics 
for 1 9 10 and the reports of the United States Bureau of 
Education. It has been found necessary, also, to study the 
work of cities having only school doctors, or only school 
nurses for comparison with the group selected. The experi- 
ences of European and other countries have also been drawn 
upon. The attempt throughout has been to fit the investiga- 
tion to the actual conditions found, not the facts to a pre- 
arranged theory or questionnaire. The heterogeneity of 
the findings by such a method, for work so new and tenta- 
tive, beggars description. 

Late in the study the writer had the good fortune to be 
employed by the Board of Education of one of the twenty- 
five selected cities, probably nearest of all to the city of 
typical size in this country, to investigate the work of the 
so-called medical inspection and to report a tentative, 
standardized plan for reorganization and growth. Full 
powers were given In the way of calling for the judgments of 
teachers, principals, physical trainers, physicians and nurses; 
and for looking into the work. Though the time available 
was entirely too short, a good deal of fresh light was thus 
thrown on the general problem. 

We shall first take up the work of medical inspection 
with its display of pathological conditions and consequent 
health needs, in the schools and homes. Later, brief descrip- 



74 SCHOOL HEALTH ADMINISTRATION 

tions and evaluations of other phases of educational hygiene 
of a preventive and development nature will be offered. 

3. MEDICAL INSPECTION OF SCHOOLS IN TWENTY-FIVE 

CITIES 

The following tables attempt to display in convenient 
form some of the main facts about the work of medical 
inspection in the twenty-five cities. Some general facts 
relating to the city and the schools, necessary for compre- 
hension of the situation and for later efficiency tests, are 
given first. Many facts refuse to enter the squares of a 
statistical table, and foot-notes, description and qualifica- 
tions are necessary. Even then the data are relatively 
inaccurate, for many reasons, but chiefly because of the lack 
of efficient records in practically all cities. When, for 
example, a medical inspector has been discharged for sending 
in reports based on nothing more than entering the lower 
hall of a school and signing his name in a book, some doubt 
is cast over his and perhaps others' statistics in that city. 
Further, most of the blank forms for recording the work 
are, as yet, so poorly devised that it is almost impossible to 
record or summarize work done, or correlate it with results 
accomplished. The poor clerks, devoid of medical knowl- 
edge, who have to make up a majority of the summaries 
from such data help to make even more inaccurate the 
results. Some cities have met the situation by making no 
annual reports or very meager and inadequate summaries. 
To get back of this difficulty it was necessary to spend 
several months in summarizing the daily, weekly or 
monthly reports of doctors and nurses in a number of cities. 
The knowledge gained from such work was, however, well 
worth the tedious labor. The large number of cases proba- 
bly helps some to cover up many inaccuracies, and the gen- 
eral facts here selected and presented are probably as accu- 
rate as can now be obtained. Our hope is that the study 
will lead to greater efficiency in this field. 



THE TWENTY-FIVE CITIES 75 

B. Correlations JVith Population of the Cities. 

From these statistics it can be seen that the cities and 
towns studied are scattered over five states and range in 
size from 7,500 population to 670,583, 1910 census. Within 
this range are included most of the municipalities of the 
country so the data of our study can be regarded as fairly 
typical in this respect. Since the cities are arranged in 
order of size (Columns i, 2, 3), questions immediately 
arise as to the correlation of this increase with the admin- 
istrative provisions. In the next column (4) it can be seen 
that as the cities increase in size more and more of them 
have medical inspection administered by Boards of Health. 
This may be due to chance, but is more probably due to the 
fact that when medical inspection began a few years ago it 
was confined for the most part to the larger cities, and was 
under the Boards of Health. The 1906 Massachusetts 
law prevents cities from taking the work, where already 
begun, out of the hands of the Boards of Health and put- 
ting it into the hands of the Boards of Education. The 
smaller cities, as shown by the column giving the dates when 
medical inspection was begun, have started the work for 
the most part since the change of public opinion and state 
laws have placed the work in the hands of the Boards of 
Education. In New Bedford and Boston the work is di- 
vided, the Boards of Health having the school doctors and 
the Boards of Education the nurses. 

I. SALARIES AND SIZE OF CITY 

Only the larger cities have special supervisors of medi- 
cal inspection, Syracuse under the Board of Health, Jersey 
City and Newark under the Boards of Education, and Bos- 
ton with a supervisor employed by each board.* No signifi- 
cant correlation exists between the size of the city and the 
salary paid either to physicians or nurses. Some small 
cities pay little and some much; the same is true of the 
larger ones. The supervisors' salaries tend to increase with 



*The Board of Education in Boston has both a general Director 
of Hygiene and a Supervisor of Nurses. 



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78 SCHOOL HEALTH ADMINISTRAION 

the size of the city, indicating, perhaps, a recognition of the 
possibilities of more responsibihty if not more work in the 
larger places (Columns 19 and 20). 

2. NUMBER OF DOCTORS AND NURSES 

When we come to the number of doctors and nurses 
(Columns 19 and 20), a surprisingly low correlation is 
found. The numbers by no means increase proportionately 
with the size of the city or the number of pupils in the 
school systems. If the first five cities require the entire 
time of one nurse each, then, taking 1,735, their average 
enrollment as a trial standard, Boston should have about 
63 nurses instead of 34 and Newark 45 instead of eight. 
Providence would have 20 instead of one. It is evident 
from these figures that there are as yet no very definite 
standards established or attained in this field. The writer 
found the nurse's time well occupied in these smaller cities. 
Since the problem increases somewhat with the size and 
congestion of the city it would seem reasonable from this 
correlation that while the smaller cities may be fairly well 
supplied with nurses, the larger cities have a woeful insuffi- 
ciency. However, the number of physicians, the size of the 
schools and the distances between them are all factors. 

There is a closer correlation between the number of 
physicians and the size of the city, than for the nurses. 
Physicians were the first to be appointed and the cities have 
been districted largely on the basis of physicians, not nurses. 
Taking the same average enrollment for the first five cities 
(15735) we find that if these small cities each need one 
physician two hours a day, Boston should have, on this basis, 
(counting each supervisor as two physicians), 63 physi- 
cians instead of 82, Newark 45 instead of 39, and Provi- 
dence 20 instead of four. It can be seen that most cities have 
fewer physicians than this trial standard calls for. 

PHYSICIAN-NURSE UNIT 

But the number of physicians employed depends largely 
upon the number of nurses in the system and, vice versa, it 
may be said; so the unit standard should really be the 



THE TWENTY-FIVE CITIES 79 

physician-wf^/z-the-nurse, the physician-nurse unit. Applying 
again the average-pupil-enrollment standard, Boston would 
have 63 doctors and 63 nurses, and the other cities 
proportionate numbers. The combined number for Boston 
would be 126 instead of the present 120, (80+2) + 
(34+2+2), a very small difference. (Column 47). For 
Newark the combined number would be 90 instead of 47, 
(37+8+2) ; and for Providence 40 instead of five. The 
combined number based on this standard is given in con- 
trast to the actual combined numbers for each city in 
columns 46 and 47. The ratio of the actual combined 
number to the standard number is given in column 48. 
Glancing down this column (48) we note an increasing 
falling away from the tentative trial standard number of 
physicians and nurses until we reach the last city, Boston, 
(95.47), where a surprisingly close correspondence Is 
reached. The only city having more than the standard 
number is Montclair and its superiority Is apparent rather 
than real, for its physicians visited the schools only twice 
a week instead of five times, and spent, on the average, 
only about one hour's time to a visit. 

THE PHYSICIAN HOURS A WEEK NURSE STANDARD 

This shows the necessity for a trial standard which will 
include the number of hours a week the physicians actually 
spend in the school work. Later a general working stand- 
ard will be developed which will include the number of 
daily visits a year, and other matters, but for the quick 
comparison of cities the following plan may be used: Count 
as a physiclan-worklng-unit one who gives five hours a 
week (an hour a day) to the schools. Rules and regula- 
tions are extremely chaotic; and It is difl[icult in^the hetero- 
geneity to learn exactly how many hours physicians actually 
do put in, on the average (See columns 30-32) ; still column 
49 will show approximately on this comparable basis the 
relative standing of the cities as to numbers of doctors and 
nurses. At Montclair, for example, the five physicians 
putting In two hours a week are roughly equivalent to two 
physicians giving five hours a week. Adding the nurse 



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82 SCHOOL HEALTH ADMINISTRATION 

(Column 49) to the physicians we have the equivalent 
(other things equal) of a working staff of three instead of 
six. While it will be shown later that probably tmo hours 
a day, jive days a week is a more ideal arrangement, "stand- 
ard" here means only a trial unit of measurement for put- 
ting variant facts on a comparable basis. Fractions should 
be considered as parts of working-units, not of physicians, 
of course. 

Leaving off the decimals, we see what a variety of things 
the statement that a city "has medical inspection of schools" 
may mean. (Column 50). Meriden stands at 100 per 
cent; while Yonkers stands at 1 1 per cent. Ten times as 
many hours of medical service were given in the former 
city (not counting the number of hours, nor daily visits a 
year)^ and to one-third the number of elementary pupils. 
Taking the average of the first five cities again as a basis 
of comparison (2, a physician with a nurse each), and 
1735 as the average enrollment, we can see how many 
physicians and nurses the cities would have were they to 
keep up to the trial standard set by the first five. Boston 
again practically maintains the custom of the small towns. 
Other cities coming near to it, after the five used as a 
standard, are: Meriden and Newark. Counting office 
assistance in Boston and Newark there would be almost the 
same proportionate amount of medical inspection units as 
in the smaller cities. In other words, the two largest cities 
almost keep up the standard set by the smallest towns while 
other cities fall considerably below. 

The percentage figures in the next column (50) show 
how nearly the different cities come to the working stand- 
ard. When we see such large and relatively efficient cities 
as Newark (95 per cent), and Boston (95 per cent), 
practically coming up to the standard set by the smallest, 
and then see Meriden starting out (October, 19 10) on an 
ably constructed plan of administration of this work and 
practically taking up this standard, it appears that the 
working standard used here must not be far from what 
actually seems necessary. Its limitations will be shown 



THE TWENTY-FIVE CITIES 83 

later. In Summit, for example, with a first-class suburban 
population the medical inspector really has to put In more 
than an hour a day five days In the week, and, to get the 
work well done, should be employed for two hours in 
actual medical work daily; but in the year studied he made 
only 125 daily visits In the school year of 188 days. 

Interpreted, some of the cases In this column mean, for 
example, in Rochester and Jersey City,* that these cities 
have about half (50%) as many inspectors and nurses as 
would meet the standard of the largest and smallest towns; 
Yonkers has about 11% as many, being most poorly sup- 
plied of all the cities. These figures, then, show the approx- 
imate relative standing of the cities as to the amount of 
medical Inspection forces per unit of school enrollment not 
counting the relative number of weeks employed In a school 
year. This does not state what should be, but what was. 
The number of nurses put into a school system would Influ- 
ence the number of physicians needed. It is probable that 
there should be at least an equal number, and perhaps more. 
No data are here given on this problem. 

3. BOARDS OF EDUCATION VS. BOARDS OF HEALTH 

Is there any light thrown by these comparative figures 
on the relative efficiency of Boards of Health and Boards 
of Education? If Boards of Health are more responsive 
generally to the needs of the schools with respect to patho- 
logical health conditions than are Boards of Education 
then we should expect these figures to show them better 
manned for the work of medical inspection, especially since 
they are, on the average, nearly three times as old. What 
are the facts? Leaving out the two cities. New Bedford 
and Boston, where the responsibility of caring for the 
health of the school children is divided between the two 



*This was the first complete year of medical "inspection" for Jersey 
City and the plan was not completely carried out. The rules require 
two hours a day, five days a week, for each physician. Were the actual 
average ten hours a week, the combined number would be i2X2-|-4H-6. 
The twelve M. D.'s would be equivalent to twenty-four, the supervisor 
to four, and the nurses to six; in all, thirty-four, instead of twenty. 



84 SCHOOL HEALTH ADMINISTRATION 

boards, we can take the average standing of those cities 
where this work is administered by Boards of Education 
and compare it with the average of the cities under Boards 
of Health (Column 50). The average for the fourteen 
cities administered by Boards of Education is 76% 
(omitting Brockton,* 81%) while the average for the 
nine cities where the work is in the hands of the Boards of 
Health is a little over 45%. This would seem to indicate 
that Boards of Health are not as responsive, or not as 
successful, in getting an adequate force of medical inspectors 
and nurses as are Boards of Education. Even leaving off 
the first five cities and comparing the nine remaining cities 
with the nine others, the Boards of Education stand at 
about 62% while the Boards of Health stand at about 

45%- 

An alternative, however, remains: That the Boards of 
Health may be able to use more efficiently a given number 
of medical inspectors and nurses than could the Boards of 
Education. This remains for later solution when the 
amounts and quality of work done are compared. It may 
be said here, however, that in general they seem to use 
them far less efficiently than do Boards of Education. 

Under Boards of Education. Under Boards of Health. 

Montclair 75 Mt. Vernon 83 

Meriden lOO Newton 87 

Brockton* 20 Schenectady 20 

Hoboken 58 Waterbury 28 

Yonkers 11 Cambridge 35 

Trenton 83 New Haven 28 

Lowell 71 Syracuse 64 

Jersey City 50 Rochester 50 

Newark 95 Providence 12 



563 407 

Average, 62%, without Brockton, 67%. Average, 45%. 

4. TENDENCIES IN MEDICAL SUPERVISION 

Without carrying any further the correlations between 



*Brockton is exceptional for the reason that it is practically elim- 
inating physicians, using them for consultation by the nurse only. This 
marks the begininng of a growing tendency. 



THE TWENTY-FIVE CITIES 85 

the increase in size of the cities and their school populations, 
we can see something of the tremendous heterogeneity and 
relative status of cities in this work. Another preliminary 
problem arises as to the tendencies shown by these 25 cities. 
How rapidly is medical supervision coming into our cities, 
and is its administration going into the hands of the Boards 
of Education or the Boards of Health? The facts are 
shown by the following table (Column 5) : 

Two began Medical Supervision in 1894, both by Board 
of Health. One now partly Board of Education. 

Two began Medical Supervision in 1901, one Health 
and one Education, formerly Health. 

One began Medical Supervision in 1903, Education. 

One began Medical Supervision in 1904, Health. 

Four began Medical Supervision in 1905, two Health 
and two Education. 

Four began Medical Supervision in 1906, three Health 
(one partly Education) and one Education. 

Two began Medical Supervision in 1907, both Health, 
one partly Education. 

Three began Medical Supervision in 1908, all Educa- 
tion. 

Three began Medical Supervision in 1909, all Educa- 
tion. 

Three began Medical Supervision in 19 10, all Educa- 
tion. 

None of the nine cities starting since 1907 has 
Intrusted this work to Boards of Health. The work began 
with the Boards of Health but it is now being placed in 
the hands of the Boards of Education. In New Jersey the 
1909 law placed all the systems then existing under the 
Board of Education, four of these cities. 

This table for these twenty-five cities corresponds closely 
to the one made for 1,038 cities giv^en earlier. It shows 
a very remarkable acceleration since 1904-5, an increase 
so rapid as to point to the movement spreading soon to all 
cities. In these cities, too, the nurses have all been added 
since 1906 when Boston started the movement on a large 



86 SCHOOL HEALTH ADMINISTRATION 

scale, practically all having been added, indeed, since 1908. 
(Column 6). A tendency, not yet to be shown in figures, 
exists toward increasing the number of nurses and decreas- 
ing the number of physicians. One city, Brockton, dropped 
three of its physicians (keeping two paid and one volun- 
tary physician for consultation only) , and put one nurse in 
their place. This was at the instance of physicians them- 
selves, one of whom is on the Board of Education. 

Newark is now changing to almost the same plan, using 
a few physicians as district medical supervisors of a large 
number of nurses. Oakland, Cal., and Albany, N. Y., have 
the same general plan. 

C, WHAT DOES MEDICAL SUPERVISION COST? 

a. Salaries of Supervisors and Office Help 

The salaries of physicians range from $200 to $1,200 
as regular examiners or inspectors. One, a member of a 
Board of Education, gives his services free of charge (at 
Brockton). The salaries of the head-physicians, or super- 
visors, range from $800 to $3,780, as follows: 

Syracuse, $800. 

Jersey City, $1,500. 

Newark, $1,800. 

Boston: Board of Health, $2,500; Board of Educa- 
tion — General Supervisor Department of Hygiene, $3,780; 
Supervisor of Nurses, $1,500. 

None of these supervisors gave full time to the work, 
excepting the woman who is supervisor of nurses in Boston. 
From three to four hours a day was expected or given by the 
other supervisors. These figures, of course, do not give 
credit to the large amount of supervising time given either 
by the superintendents of schools or of boards of health in 
certain cases. They refer only to those officials who have 
been definitely set apart for this specific work alone and 
who are paid a salary for it. Each of these supervisors has 
office help, either the general office force as in boards of 
health, or special assistants as in the case of the schools. 
Jersey City has one stenographer on half time, and here 
only records of excluded children are summarized. In New- 



THE TWENTY-FIVE- CITIES 87 

ark, the supervisor has a well appointed office and two 
efficient clerks on full time. Even these are not able to 
do all the work desirable to keeping track of 37 to 38 
inspectors and eight nurses with daily reports, a sani- 
tary inspector and large amounts of medical supplies. 
Analysis of results and adequate checking up and reporting 
are difficult. In Boston, the school Supervisor of Hygiene 
and the Supervisor of Nurses have but one clerk. To meet 
this situation nurses are there required to hand in reports 
only every three months. Of course, there are no physicians 
to look after as they are under the direction of the Board 
of Health. The efficiency of reporting only every three 
months instead of daily or weekly is very doubtful. 

b. Salaries of School Physicians 

The gross salaries of physicians seem very low. The 
average salary is $398, practically $400 a year.* The 
median salary is, however, only about $300, half of the 
cities having less than this salary and half having more, 
while only six pay more than $400. The three cities which 
pay $1,000 and over are exceptional. In two of these, as 
will be shown later, the salary is probably higher in pro- 
portion to services rendered than is necessary. Distinctions 
must continually be made between the number of hours 
required by the rules or expected by the Board and the 
number of hours which are actually given to the school 
work. These three cities require twice or three times as 
much time a day as is customary, two and three hours 
instead of one. Boston had 80 physicians at a dollar or 
less an hour; for some physicians put in more than the 
required hour a day. This has since been changed to two 
hours a day and $500 a year. 

A salary of $300 for ten months, counting twenty 
school days to a month, and a visit of an hour a day, five 
days in the week, means $30 for 20 hours, or $1,50 a visit, 



*Newark has since changed from thirty-seven physicians at $300 
a year to thirty-eight physicians at $400, giving strictly two hours to 
the school work each day since many physicians have but one school. 
Further changes emphasizing the nurse are now taking place, however. 
See page 84. 



88 SCHOOL HEALTH ADMINISTRATION 

or hour. $400 means $2 an hour. These are not far 
from the regular charges of average physicians in private 
practice. The public service is far more regular, very few 
patients indeed requiring a physician's services daily nearly 
180 times a year. It, moreover, brings the physician into 
touch with a great number of present and future citizens, 
which will, in many cases, increase his practice. The main 
drawbacks seem to be, first, that the school hour, or hours, 
should be given at practically the same time each day, thus 
interfering with possible private practice; second, that the 
work is of such a routine character that the physician very 
soon tires of it; and third, that the conscientious physician 
is frequently disheartened in the attempt to do in an hour, 
an hour-and-a-half, or even two hours, all that needs to be 
done in service to the children. To emphasize the second 
point, Dr. Cornell's frequent mention of the physical strain 
of prolonged examinations may be quoted from his book 
on "Health and Medical Inspection of School Children." 
In speaking of vision testing, page 42, he says: "Anyone 
who has examined for two hours, alternately standing beside 
a test card with a pointer and going to a table or desk to 
make the record, using constantly the eyes, voice, and body, 
with the added effort of instructing each child clearly what 
to do and how to do it, will testify to absolute fatigue experi- 
enced, as well as the feeling of eye-strain ensuing." And 
again on page 43, "An hour and a half of eye testing is 
almost sufficient to start up a headache in any examiner, 
no matter how perfect his eyesight, and phlegmatic his 
temperament." These effects are practically universal and 
are mentioned by most of the English writers on this siib- 
ject. It would seem that the strictly medical examination, 
not including vision or hearing tests, is just as fatiguing and 
that those who claim physicians should be employed for 
the entire day (excepting the supervisor who could vary 
his work) as is the teacher or nurse, are wrong; and the 
best scientific management would make the physician's 
expert services last little longer than two hours daily. For 
full-time service the problem becomes one of providing 
other work for each half day. The nurse, of course, can 



THE TWENTY-FIVE CITIES 89 

easily alternate her work with home visiting. It is doubtful 
if any first-class physicians could be found who would de- 
vote their entire days to medical examinations of pupils. 
All the writer has questioned asserted this emphatically. 
The ideal for the physician at present would seem to be 
two hours a day, taking no part of the two hours in going 
from one school to another. Inevitably school physicians 
will, however, be provided on full time. The problem 
has not yet been solved. Several very large cities now 
have full-time physicians, of course, but the salaries are 
large, and we are looking here more to average or typical 
cities. 

These salaries as printed, however, do not show com- 
paratively what the real salaries are. The number of hours 
a day, week, and year, the quality and the difficulty of the 
service must all be considered. Leaving out the last two 
for the present, let us see what the salaries are in terms of 
hours spent in the school service. Columns 32 and 51 give 
respectively the number of hours a week each physician 
gives on the average, as nearly as could be determined, and 
what each hour cost the city. The second column then 
gives fairly accurately the real comparative salaries, omit- 
ting the number of daily visits in the school year, which 
varies greatly. Where cities have no rules governing this 
matter or have physicians only "on call" estimates have 
been made, with the help of some supervising official, of the 
average number of hours a week inspectors spent in the 
schools. Likewise, where the work is new and the adminis- 
trative measures not yet perfected estimates have necessarily 
been used. Some inspectors will perhaps find that their 
individual amount of time is underestimated by these figures; 
others, overestimated. Had we facts for all cities the num- 
ber of daily visits a year should be taken into consideration 
as an important item. Wholesale absence is common in 
some cities. 

These salaries stated in terms of wages-per-hour 
range from $1 to $6.25. If it could be shown that the 
physicians at Yonkers gave an average of more than an 
hour a day twice a week, then this largest salary would be 



90 SCHOOL HEALTH ADMINISTRATION 

decreased, and perhaps some other city would stand highest. 
The facts are for the year 1910-11. The average wage per 
hour for the 25 cities is $2.30 and the median wage is $2, 
half of the cities paying less than this amount and half pay- 
ing the same or more. Only five cities pay more than $2.50 
an hour and only three pay as low as one dollar. If the 
four cities paying over three dollars actually had a larger 
average number of hours service for each physician, which 
may be possible, the average and the median for all would 
not be far from $1.50 an hour. The Newark change from 
$1.50 to $2 a visit of two hours each, five days a week, is in- 
teresting in this connection. Of course, where the calendar, 
instead of the four-weeks school month, is used, physicians 
get a little less an hour. It is very doubtful if it is an effi- 
cient use of public money to pay more than $1.50 an hour 
(three dollars for a two-hour visit). If Boston can get 80 
physicians year after year, Newark 38, and many other 
smaller cities can get good average physicians for a dollar 
an hour, this sum, especially in the two hour a day plan, 
would seem to be a reasonable minimum. Sixty dollars a 
month regularly ($1.50 an hour) seems to be average 
physicians' earnings, much better than many, and better than 
the teachers in the schools obtain. Where more is paid, 
say two dollars an hour or $800 a year, diminishing returns 
bring in the school nurse who can be had on full-time 
eleven instead of ten months in the year, and who is often 
more efficient hour by hour for the relatively simple work 
of school Inspection than the physicians. 

c. Nurses' Salaries 

The salaries of nurses are fairly well standardized. 
Nurses in a large number of schools work from 8 :30 or 
9:00 in the morning until 4:00 to 6:00 in the afternoon, 
with a half hour to an hour off for lunch. Generally the 
plan Is to have the nurse at the school about fifteen minutes 
before school begins in the morning; and to require her to 
do home visiting after school until five-thirty or a little later. 
Home visiting may also be done in school hours in many 
places. On Saturday, the nurse makes home visits from 



THE TWENTY-FIVE CITIES 91 

eight or nine to twelve o'clock. For these five-and-half 
days a week with Saturday afternoons frequently devoted to 
statistical records and reports, the nurses receive salaries 
ranging from a little over fifty, to ninety dollars a month, 
ten, and, in some cases, eleven or twelve months in the 
year. Boards of health quite regularly, though with excep- 
tions, employ the nurses for twelve months with salaries of 
eight or nine hundred dollars a year. In the summer and at 
other times when not engaged in school medical inspection, 
the Board of Health nurses do the regular district and 
other nursing. 

In Schenectady the nurses each spend a month of the 
summer in the Open Air School with one month vacation 
each. In Boston, the school nurses are paid in twelve 
annual installments and may be called upon for service 
during the summer vacation, but as yet they have been 
free. The tendency is toward keeping a part or all of the 
nurses in relays during the summer (each nurse getting a 
month's vacation) for the inspection of children in vacation 
schools and playgrounds and for the home visiting which 
seems necessary to prevent immense accumulations of cases 
of pediculosis, impetigo, and the like for the beginning of 
the school term. The salary of the only head nurse, or 
supervisor of nurses (in Boston), is $1,500.* She and the 
other nurses are on a salary schedule which rises with years 
of experience and growing skill. This latter desirable 
measure tends to put the nurses on the same professional 
plane as the teachers. The tendency is for the nurse's 
salary to be as high as that of the teacher. Her work is 
perhaps a little longer but on the average her professional 
training and years of preparatory schooling are much less. 
Her night work also Is probably very much less than that 
of teachers. 

The average salary in the 25 cities Is $756 while the 
median is $750, for ten months. A number of nurses are 
paid for an extra month In the summer over this sum. 

*More now. 



92 SCHOOL HEALTH ADMINISTRATION 

d. Total for all Medical Supervision Salaries 
The total for all salaries of doctors and nurses is given 
in column 25. The seeming discrepancy for Newark arises 
from the fact that until February of the school year, 19 10- 
191 1, there were 16 doctors on a salary of $400 a year, 
ten hours a week; while after that date there were 37 doctors 
on a salary of $300 a year, ($ .75 an hour) giving the 
same time.* In three cases, as shown (Montclair, Cam- 
bridge, and Lowell), the Boards of Health have employed 
other physicians to inspect the parochial schools. The 
physicians of no Board of Education as yet inspect private 
and parochial schools. The Boards of Health have exer- 
cised such rights because their general health powers are 
so great. Where state laws require medical inspection 
of parochial schools, the latter are coming to ask boards 
of education to do it, however. 

2. SUPPLIES AND OTHER EXPENDITURES 

a. Carfare. {Column 26.) 

As physicians frequently have automobiles or other con- 
veyances, they are not usually given car tickets. The 
nurses are nearly always given such tickets. In some cases, 
e.g., the small towns near Boston or New York, railroad 
fare is also included whenever a nurse takes a pupil or a 
group of pupils in to a free clinic or specialist. Permission 
is, of course, granted by the parents for such cases. The 
median allowance for carfare, so far as it could be dis- 
covered, seems to be about thirty-five dollars a year for 
each nurse. The 35 nurses in Boston required only $408.50 
for the year, an average of less than $12.00 each ($11.66) ; 
and this sum Includes the supervisor who probably spent 
far more on the average than the other nurses. Where a 
large city Is well districted and there are many nurses, such 
expenditure, will be, of course, largely reduced. 

b. Printing 

The printing expenditures (Column 27) are for medical 
supervision blank forms, notices to parents, and the like. 
Where daily reports are made on printed postal card forms 



*From February 1st, 1912, there have been thirty-eight doctors on 
a salary of $400 a year each, a rate of about one dollar an hour. 



THE TWENTY-FIVE CITIES 93 

or sent in stamped envelopes, postage becomes a large item. 
In Newark, counting 180 school days, for 45 medical 
assistants (doctors and nurses) and two cents for each daily 
report, the item amounts to about $162. This cost is 
included in this column. Meriden, the seventh city, hap- 
pens to show the initial cost of printing, when the system 
was started. After a system has been well started and a 
reasonable supply of materials laid in, little needs to be 
paid for further printing. Where poorly considered forms 
have been printed in quantities, great amounts of obsolete 
forms and waste of money accumulate. Certain cities have 
so many different forms that the whole system is confusing, 
and doctors spend almost as much and even more time in 
making the daily reports, in their school time, as in inspect- 
ing or examining children. For a city of about thirty to 
fifty thousand population the cost of introducing a com- 
plete system of blank forms, nurses' equipment, etc., need 
not be much over $200. 

c. Medical Supplies 

The cost of medical supplies (Column 28) varies very 
greatly because of the great variance of opinion on treat- 
ments. Some hold that the schools have no business in this 
field while others contend that free treatment is not any 
worse and just as desirable as free books and free school- 
houses, especially since we have compulsory attendance and 
so compulsory danger of infection and unhealthful school 
environment. Some cities have such supplies in large quan- 
tities kept at the central school supply center and deliver 
them when needed, on requisitions from the principals. 
Others keep all the supplies in the separate schools; while 
some have the only supplies used in the nurse's bag (e.g.. 
New Haven) which she carries from school to school. 
Again, some cities buy as the supplies are needed from the 
local druggists while others buy for a year at a time from 
wholesale medical supply houses, choosing the lowest bidder. 
Very little study by school business managers and others 
has been made of the most efficient buying in this field. 
Buying of local druggists seems to be quite expensive as 



94 SCHOOL HEALTH ADMINISTRATION 

items are overcharged. The investigator found in one city, 
for example, twenty-five cent hair brushes (for vermin 
cases) sold at $1.50 each. Most supplies keep well enough 
to be purchased for a year ahead, and this seems to be the 
best method, if the requisitions are made out with sufficient 
care and real public bidding by the best firms is solicited. 
A list of the principal supplies found necessary in the most 
progressive school systems will be given later. The cost 
of such supplies in the most liberal cities is comparatively 
very little. In these twenty-five cities the expenditure ranges 
from about zero to nearly three thousand dollars (New- 
ark) . The tendency will inevitably be in the direction of 
increasing the amount of free treatment. The writer's 
judgment on the matter will be found in the tentative 
standard plan offered for criticism in the last chapter. 

3. TOTAL EXPENDITURES FOR PUBLIC SCHOOL MEDICAL 

INSPECTION 

The total expenditures for Medical Inspection in the 
schools studied are given in column 29. In cases where the 
cost of supplies and other items could not be separated from 
general expenditures, the expenditures would be somewhat 
larger. Where the Board of Health has the school physi- 
cians and the Board of Education the nurses, numbers 
above are those for the latter, and those below for the 
former. The relationship of these expenditures to the total 
running expenses of the schools is given in column 53. The 
general correlation with total school expenditures can be 
seen from inspection to be very slight, as has before been 
pointed out in another connection. 

D. Management of Medical Supervision Work. 

I. TIME EMPLOYED BY DOCTORS AND NURSES 

The school nurse, as suggested, works, on the average, 
five and a half days a week, giving seven to eight hours a 
day on school days and three to four on Saturday. Her 
total weekly hours are, therefore, very much in excess of 
the time put in by the average physician. In actual hours 
the average weekly time in hours of the physicians is to 



THE TWENTY-FIVE CITIES 95 

the average of the nurses in these twenty-five cities as i to 
7 or 8. This ratio, by a coincidence, is that often given by 
those in charge of such work as to the relative worth to 
the schools of doctors and nurses. When a system has been 
properly organized, however, the physician will do only such 
highly skilled work as the nurse cannot do, and for the 
same amount of time the ratio will be smaller. Fortunately, 
the most common ailments of school children are so simple 
that they can be easily and efficiently handled by the well- 
trained nurse. There is no such responsibility for life and 
limb as the physician carries when he takes his cases in pri- 
vate life. For the nurse, there is nearly always the family 
physician or dispensary to check up her management of 
cases. The disadvantages of having physicians call at 
schools only once or twice a week, cultivating their private 
practice on other days at the regular school time, are so 
great and so numerous that it is being found best to have 
them go to the schools at the same time every school day. 
As will be shown later there is also a decided advantage 
in having the time spent by the physicians in the schools not 
less than two hours. And further, in this connection, in 
order to save the vast amount of time lost in traveling from 
school to school on any one day, it will be found more 
efficient to have the physician visit only otie school a day; 
perform only the technical part of the annual examinations; 
and spend all of the two hours or more required in the one 
school, visiting, perhaps, five schools in the five days. The 
time for physicians each day should begin about ten min- 
utes before school begins, so they may, in the schools where 
they examine, individually inspect such pupils, also, as have 
been out of school for several days or such as seem to the 
teachers or nurses to require immediate and skilled atten- 
tion at the opening of school. 

2. CHECKS ON THE WORK OF MEDICAL SUPERVISORS 

School Physicians. No very efficient and entirely satis- 
factory checks on the work of physicians have yet been 
devised. Supervisors who have had experience in medical 



96 SCHOOL HEALTH ADMINISTRATION 

inspection work realize most the importance of devices for 
obtaining regularity and punctuality as well as accuracy of 
reporting and conscientiousness of pupil examination. The 
work is often looked upon as a "public plum" to be had for 
the picking — a little necessary money and very little work. 
The schemes devised for appearing to be at schools where 
they have done no work by physicians who have been turned 
off or reprimanded are startling in the extreme. One 
Board of Health officer said if he had his way he would 
turn off all his inspectors but one, but politics kept them in, 
though inefficient. 

The checks at Newark are Interesting and seemingly 
quite effective. Physicians are carefuly selected by the 
supervisor with the help of a written examination. Further- 
more the supervisor (Dr. Geo. J. Holmes) frequently 
visits the schools and sees the Inspectors at work. There 
are also monthly meetings of all doctors and nurses with the 
supervisor. But the checks, proper, come in the following: 

1. A daily report of work done, in detail. 

2. Occasional telephone calls to physicians or nurses at 
the schools, on business. 

3. A schedule of visitation, so each doctor knows where 
he is expected to be at any time. 

4. Principals' reports on the work of doctors. 

5. Physician must sign a book in the principal's office on 
coming to the school and on leaving, and must give the time 
spent, in his dally report. 

6. A monthly summarized report. 

7. Conferences with teachers and nurses on their co- 
operation with the physicians. 

8. Requirement of early notice on days when sickness 
keeps the physician (or nurse) at home so a substitute may 
be sent, the latter drawing the former's pay. 

The necessity for careful checking up on physicians at 
work in the schools grows out of the psychological nature 
of the situation. There Is a strong tradition that public 
office is a public sinecure; school work Is monotonous and 
uninteresting to many; It furthermore Interferes with the 



THE TWENTY-FIVE CITIES 97 

regular practice of the physician; and, finally, the pay Is 
small; so the best and even the most public-spirited physi- 
cians are not, as a rule, drawn into the work. Where a sys- 
tem of medical inspection has, for example, been taken 
over by the Board of Education after having been in the 
hands of the Board of Health for a number of years, it has 
been found necessary, in order to get real efficiency in the 
work, gradually to dispense with the services of practically 
all physicians who had participated in the old, shiftless, 
time-serving system. A man once habituated in such a 
system will not usually change over into an efficient exam- 
iner or inspector under the new order. It is necessary as 
soon as possible to get new men and start them in right. 

The checks for physicians found in these cities are 
given in column 37 and are seen to vary from zero and 
so-called "annual reports" down to an elaborate system of 
daily reporting. The efficiency of the systems will, in gen- 
eral, be seen to correlate closely with the shortness of the 
period reported. Especially where there is a very large 
number of physicians is this true. In a small system with 
a superintendent interested in the efficiency of the work, 
elaborate checks and daily reporting are not so necessary. 
Where in a small sytem a supervisor of (educational) 
hygiene is put over the work, mere checks are not so 
important as the need for accuracy of reporting; and this, 
of course, is all the way through an important reason for 
frequent reports carefully made out and balanced in some 
way. Close personal supervision decreases the need for 
checks. 

There are good arguments for either a report sent In 
daily, or a weekly report which gives each day's work and 
in some way rounds out the week. The latter is especially 
desirable where there Is not an adequate central clerical 
staff for summarizing reports, and where it Is desired to 
have the doctor's and nurse's reports sent in as one sum- 
mary, giving both the number of ailments and what was 
done with them. No city yet follows this plan. The daily 
reporting systems now In vogue have for the most part. 



98 SCHOOL HEALTH ADMINISTRATION 

it seems, been devised, and are being supervised and car- 
ried out, by men who have been school inspectors and 
know the nature of the problem. Monthly reporting, or 
any reporting for a longer time than a week seems to lead 
in most cases to inaccuracy and less careful work. I shall 
try to show this later where the factors which go to make 
up efficiency are set forth in figures. 

One of the most exasperating sources of inefficiency in 
this field, as suggested, is a complicated system of reporting 
which tediously takes up much of a physician's time. Dr. 
Cornell shows the physician's side of the matter quite 
lucidly in his book, "iHealth and Medical Inspection of 
School Children," page 46: 

"In our large cities, however, there is a tendency toward 
too much book-keeping by the school physician, and it is not 
unusual for one-half or two-thirds of the medical examiner's 
time to be consumed in the writing of multiple reports and 
complex records. Many of them are futllely devised to 
take the place of personal supervision, which, as has been 
noted, is essential in the conduct of miedical inspection on 
a large scale. Their aim is not to record useful facts, but 
to check up the inspector's work and personal honesty. 
Failing to do this, because it Is just as easy to record a false 
entry four times as It Is to record It once, hundreds of 
dollars worth of stationery and thousands of dollars worth 
of salaries are wasted." 

Any system that can be devised which will save the 
physician's time in making reports and at the same time 
insure careful work and accurate reporting is greatly to 
be desired. The standard plan offered in a later chapter 
dispenses with practically all reporting by the physician and 
gives it to the nurse. The nurse costs on the average for 
each hour of service about $ .50 (38 hours a week, 152 a 
month, at $75); while the physician costs, at least, twice 
this sum. It is poor scientific management which does not 
limit the physician to such technical work as the nurse cannot 
do well. The nurse can make out reports for herself and 
for the physician; and she can do much of the other work 



THE TWENTY-FIVE CITIES 99 

which the physician is now doing. The nurse, giving full 
time to the schools, can, moreover, be held more strictly 
to account and will feel more the whole scope and continu- 
ity of the work if she makes the combined report. In some 
school systems visited the nurse went her way and the 
physicians went their ways, each disregardful, quite largely, 
of what the others were doing. They should work as a 
team, each complementing the work of the other. 

3. VISITS AND SCHEDULES 

Many of the cities more experienced in the work have 
definite daily schedules for both physicians and nurses. For 
nurses, the schedule is practically universal. The number 
of schools assigned to each physician and nurse is given in 
columns 41 and 42, and the number of pupils in columns 
39 and 40, and in later columns. Boston had a physician 
for each school, elementary and high, on the average, 
and one nurse for each two schools (now nearly as many 
nurses as large elementary schools). Waterbury has seven- 
teen schools, many quite small, for the physician; while 
Providence has 40 schools for the one nurse. Since many 
or most of the cities, excepting Brockton, throw many ob- 
stacles in the way of the nurse doing much work of inspec- 
tion, rules quite frequently prohibiting it except for very 
minor cases, it can be seen that daily inspection of pupils at 
all schools by physicians is out of the question in the short 
daily time in most cities. The time would be used up in 
mere school to school travel. Yet daily inspection at each 
school is the ideal of all these cities. The usual plea is for 
more physicians with which to meet this condition. Two 
alternatives seem not to have occurred to any city. First, 
combine all the phases of educational hygiene into one de- 
partment; dispense with the services of the physical train- 
ing supervisor, if any, and make director of the hygiene 
department for full time a man who is both a physician 
and a physical educator. This will give correlation and 
skilled supervision, making easily possible, second, the limi- 
tation of physicians to such medical work as cannot well be 



loo SCHOOL HEALTH ADMINISTRATION 

done by nurses, and the Increase of the powers of the nurses 
so they may do much or most of the work of daily inspection. 
This is, however, the tendency. The Brockton nurse uses 
the physicians only for consultation purposes; New York 
City (Bureau of Municipal Research and Board of Health) 
has demonstrated that the nurses can inspect for infectious 
diseases and in some of the twenty-five cities nurses have 
found more cases of infectious disease then have the doctors 
(Norwood, Winchester, Montclair, Providence, and Bos- 
ton, Cols. 206 and 207). If the nurse can make the daily 
inspections, which are almost entirely for the purpose of 
nipping epidemics of infectious diseases in the bud, the 
physicians need not spend time traveling from school to 
school, but can go to but one school a day, five a week, or 
ten in two weeks, if desired, thus reaching each school once 
a week, or once in two weeks, on a routine schedule and at 
the same time being on call from the nurse in case she is 
perplexed at any other school. The nurse could be on a 
schedule, and when her teachers were trained to detect the 
symptoms of infectious disease, she could avoid travel to 
all of her schools each day by judicious use of the telephone. 
(See the last chapter.) 

4. EXAMINATIONS AND INSPECTIONS 

Another great source of waste and confusion in this field 
Is the almost universal failure to distinguish between making 
a careful, complete physical examination, similar to or better 
than an insurance examination, of a pupil, and a very partial 
examination, such as looking at only the hair of pupils of 
a room or passing up and down the aisles looking at only 
the hands and faces, for vermin or for Infectious diseases. 
As a consequence, it has been almost impossible for the 
writer to determine for each city how many children have 
been given a complete physical examination. Some use the 
term "physical examination" and "examination" to distin- 
guish but this merely leads to confusion. The writer has 
been driven to adopt for his own use the following defini- 
tions, which he recommends for standard usage. 



THE TWENTY-FIVE CITIES loi 

Physical examination, or better, merely examination is to 
mean the complete, physical examination of a pupil to learn 
his general health condition, his physical defects and any- 
thing about his physical make-up which will militate against 
his school or physical progress. The examination will prob- 
ably best be made once a year; and may be made by one 
or more persons, preferably, perhaps, by the nurse for vision 
and hearing tests and any other phases she can do well, by 
the medical examiner (heart and lungs, adenoids and ton- 
sils, and certain other technical phases), and, third, by the 
teacher of physical training (height, weight, and chest ex- 
pansion if these are thought desirable and required). To 
this in some schools (e.g., Cleveland) is now added the 
examiner for mental defects. Other systems have dental 
examiners and oculists. All of these persons together make 
the single, annual examination. 

Inspection is a good word to use to mean any partial ex- 
amination outside of the complete physical examination. Our 
first school medical work was "medical inspection'' because 
no physical examinations were given, we might say. Any 
looking at a pupil for any special signs, or any study of him 
by health officials apart from the complete annual physical 
examination is an inspection. Cities are trying to give each 
pupil one (physical) examination a year; they may give a 
pupil fifty inspections in a year if he requires it. A case 
of pediculosis may easily require fifty inspections before it 
is thoroughly cured. It may have been found first by doctor 
or nurse at the time of the examination. 

If the nurse working alone examines fifty pupils today 
as to sight and hearing, how shall she record her work? It 
is only a part of the annual examination. This makes neces- 
sary a distinction between the "medical" and the "scholastic" 
examination; or, she may record so many examinations of 
vision and hearing and these can be combined with the re- 
port of the medical examinations by the doctor when they are 
made. This will prevent reports of two or three hundred 
or more "examinations" for from twenty-five to a hundred 
pupils. There can not be more physical examinations than 



I02 SCHOOL HEALTH ADMINISTRATION 

there are pupils examined. Re-examinations can be called 
inspections or simply re-examinations. 

Bringing together here the writer's classification of the 
many kinds of work being attempted in these cities in the 
field of inspection and examination we should have for 
any city with a fairly complete system : 

A. Examinations — complete physical, once a year. 

1. Medical, only such phases as the nurse cannot do 

well, by doctors and dentists. 

2. Scholastic, vision and hearing, and perhaps other 

phases by the nurses. This is now being done 
by teachers in three or more of the five states. 
Vision may be tested by oculists. Principals may 
make both tests. 

3. Anthropological, height, weight, chest expansion 

and other similar measurements, by physical 
training teachers or nurses, if required. They 
are of no value as usually taken, and are practi- 
cally never used or needed where well taken. 

4. Psychological, for suspected cases of mental de- 

ficiency, or other abnormal mental conditions. 
5. Work Certificate, probably not necessary in elfi- 
cient systems. 

B. Inspections — as many a year for any child as he 
needs to be seen, after or before the examination — also used 
for school building and home. 

1. September room-inspection — quick inspection of all 

pupils at the beginning of the school year or term, 
room by room, doctor and nurse working as a 
team, one medically inspecting, the other record- 
ing. May be had oftener if desired. If so, 
they should be called general, or routine room- 
inspections. 

2. Occasional room-inspection, any other room inspec- 

tion after the general one in September; might 
also be called a special room-inspection. 

3. Individual inspection — any inspection of a pupil 



THE TWENTY-FIVE CITIES 103 

apart from group inspection — pupils in their 

homes, pupils returning after exclusion or other 

absence, pupils referred to either doctor or 

nurse, etc. 

4. Home-hygiene inspection — by nurses. Recorded 

on pupils' individual health record cards. 
5. Sanitary inspection of the school, or "school sani- 
tary inspection." By any competent person dele- 
gated for this work. Recorded on a special 
school sanitation record card for each school, 
such as is used by the Philadelphia Board of 
Health. See Burks' "Health and the School," 
pages 187-8. 
With this distinction between inspection and examination 
in mind it is possible to see where most cities stand in this 
matter and to determine whether they have merely "medical 
inspection" systems or something broader and more educa- 
tional which the writer frequently calls "Medical Super- 
vision" for want of a better term. Health Supervision has 
been suggested, but this is bad in that all phases of educa- 
tional hygiene are really Health Supervision. Health In- 
spection is weak at both ends, as a term. Cities with no 
physical examinations are medical inspection systems; those 
having examination require a broader term. There seem to 
be only two disadvantages in the adoption of the term Medi- 
cal Supervision, namely, that "Medical Inspection" is the 
term now used in most cities and state laws, and that directors 
of different phases of school work are usually called "super- 
visors," e.g.. Supervisor of Drawing; and Supervisor of 
Medical Supervision does not make a very good term. He 
may, of course, be called director of hygiene if head of the 
whole department of school health, or "director" of medical 
supervision, if not. On the other hand, a good term can be 
helped to win its way; and only in the largest cities will there 
need to be directors of medical supervision, for in smaller 
cities the general health and physical development super- 
visor in whose department medical supervision is but one di- 
vision, can be termed Director (or Supervisor) of Hygiene. 



104 SCHOOL HEALTH ADMINISTRATION 

Since medical inspection is only part of the school medical 
work, it is very awkward and unfortunate to use it as part 
of the term covering all school medical work, as is now so 
often done. Considerable reflection on the already fixed 
character of medical "inspection" in state laws and common 
thought leads, however, to its reluctant use here. We shall 
hereafter use the term medical inspection. After this analysis 
and classification of school medical work, we can look at the 
tables to see at what stage our cities stand, from mere in- 
spection for infectious diseases, very few of which ailments 
are found in schools, up to all-round, effective medical pro- 
visions, including annual examinations and frequent inspec- 
tions for all pupils, and putting the emphasis upon cures and 
prevention instead of merely finding "cases." 

5. NUMBER OF PUPILS FOR EACH DOCTOR AND NURSE 

The number of children supervised by each doctor and 
nurse depends upon the kind of system, from mere inspection 
for infectious diseases up to the most intensive kind of edu- 
cational health work and consequently fewer children, and 
upon the degree of development of the system. Many school 
systems start out with a few doctors and nurses in the hope 
of later obtaining an adequate number. The great danger 
here is that the first tentative steps may be taken as a per- 
manent standard, just as emergency and monitorial teaching 
of fifty to eighty pupils in a school room has grown into 
established custom In many places. The number of children 
for each doctor and nurse is given for elementary children 
for the reason that most of the cities give very little or no 
attention to high school pupils in this particular. 

The reasons given for the neglect of the high schools are 
as follows: — 

a. Most medical work Is found in the first four or five 
grades of the schools. Very little, comparatively, Is found in 
the upper grades and high school. 

b. High school students belong to a social class that does 
not respond well to the efforts of doctors and nurses. Fur- 



THE TWENTY-FIVE CITIES 105 

thermore, the pupils are older and better able to care for 
themselves and to obtain private medical service. 

c. High school teachers are not so helpful as are the 
elementary teachers in referring ailing and defective pupils. 

d. Departmental work in the high schools makes room- 
inspection of pupils more difficult. 

e. The physical training directors of the high school in 
certain cases call the attention of pupils to ailments or de- 
fects urging attention by the individual pupil or by family 
physician, especially in the few fortunate places where such 
teachers are also physicians. 

/. The age of the high school pupils makes them more 
sensitive and reticent. Cities (e.g., Newark) that have 
tried to give adequate and thorough medical examinations by 
baring pupils to the waist have had some trouble in carrying 
the work on. All, however, have not. 

The best example of what need there is In high schools 
for medical supervision and what can be accomplished there, 
has perhaps best been shown by Prof. Thos. Storey, M.D., 
in charge of the gymnasium at the College of the City of 
New York and the high school connected with it. (See 
report of this work in the next chapter. Dr. Storey shows 
that medical work in the high school is of very great im- 
portance and that very much can be accomplished in the 
way of cures.) 

The neglect of the high school and even the fifth to the 
eighth grades by many of the twenty-five cities studied (only 
three or four having done anything at all with the high 
school problem) makes It necessary to base computations as 
to the number of children for each doctor and nurse on the 
number of elementary pupils. These numbers are given in 
columns 39 and 40. For physicians, the average number of 
pupils each ranges fromi about 651 In Montclair to 12,077 in 
Waterbury. Since the physicians give irregular time, how- 
ever, it is necessary to use the "equated physician" unit which 
takes into consideration the number of hours a week the 
physician works. The number of pupils for each equated 
physician Is given in column 43 with the number of schools 



io6 SCHOOL HEALTH ADMINISTRATION 

for each in column 42. The average number of elementary 
pupils for each physician on this basis is 3,407 and the 
median number 1,631. 

The number of elementary pupils for each nurse ranges 
from 1088 up to 15,702. 

Where the physician is unnecessarily called upon to make 
vision and hearing tests, to count the number of decayed 
teeth with the use of a tooth mirror requiring sterilization 
for each child, to make anthropological measurements of 
height, weight, chest expansion, etc., and, finally, to make 
out duplicate or triplicate cards of several varieties, forms 
and colors, it can be seen that fewer children can be handled 
In a year by each physician than in a more efficient system 
which eliminates much of this labor or gives it to the lower 
salaried and full-time nurse. 



CHAPTER V 
THE NATURE AND EFFICIENCY OF THE WORK DONE 

After a study of the agents of medical inspection, their 
number, their cost, and their administration, comes naturally 
the problem of their accomplishment. The work of medical 
inspection in public schools easily divides into ( i ) the finding 
of the children who need medical attention, (2) getting them 
cured of their ailments and defects, and (3) preventive 
measures for making the former effort unnecessary. To 
make a simple, adequate classification, statement and test of 
the heterogeneous work now being done in these twenty-five 
cities, with their reports of all degrees of completeness and 
accuracy, is a task at present practically impossible. What 
is here presented is only a beginning and cannot lay claim to 
very great accuracy or finality. The hope is that certain 
general tendencies may be brought out and that future in- 
vestigations of this subject may be made more easily. We are 
interested here not so much in the purely medical or purely 
scientific aspects of the problem as in the actual administra- 
tion and its improvement. 

In general, it may be said that the physicians, nurses and 
teachers find the ailing pupils, the nurses do most in getting 
treatments and cures, while there are no single preventive 
agents unless we might mention here the physical training 
teachers, the teachers in open-air schools, and a few others. 
As a brief introduction to the following tables setting forth 
the work done we shall give some of the generalizations 
which developed while travehng about from city to city study- 
ing this work : — 

a. The focus of attention in most medical inspection sys- 

107 



io8 SCHOOL HEALTH ADMINISTRATION 

tems Is not on prevention and cure but on the finding (in- 
specting) of the cases. When asked for the purpose of the 
medical inspection work, In only one or two cases out of many 
have school physicians emphasized getting and recording 
treatments and cures. Even though all these cities have 
nurses, therefore, it Is impossible from most reports or any 
other records to show the real efficiency of medical inspection 
In the amehoratlon of, health conditions. 

b. Most medical inspection Is "Inspection" and little more. 
Very few cities give complete physical examinations to even a 
part of the children each year. South Manchester is prob- 
ably the only city that examined all school children in the 
school year studied, and exceedingly few examine high school 
pupils. The word "examination," as related, is often used 
for inspection : an Incomplete physical study of a child, usu- 
ally for only a few symptoms like those of infectious dis- 
eases, pediculosis, or cleanliness. Further, teachers, nurses, 
and physical training teachers often make the parts of an ex- 
amination, especially those relating to vision and hearing, and 
this has complicated matters. In some cases, too, voluntary 
agents have come In — dentists especially — and have made 
the oral and teeth examinations. Most physicians and nurses 
met distinctly favored one complete physical examination 
for each elementary and high school pupil In the school sys- 
tem annually, but did not unanimously think it feasible to at- 
tempt it where there was but a small inadequate force. Only 
certain deep-lying. Incipient, or Insidious ailments are 
missed when there is careful "Inspection" without the annual 
examination. The more serious heart, lung, nervous or di- 
gestive system ailments, vision and hearing defects, adenoids, 
and the like, are frequently suspected, and the pupils re- 
ferred to family physicians or dispensary without it. The 
Importance of the many cases missed, however, is the reason 
for the thorough and complete examination. To repeat, we 
shall use here the term "examination" to refer to the single 
complete study, often made by more than one person, and 
the term "inspection" to refer to any medical study or look- 
ing at the child outside of this examination. 



EFFICIENCY OF HEALTH WORK 109 

c. The difficulty of accurately recording the total number 
of children examined and inspected with the number of new 
cases found and the number of inspections ("old cases") 
that were necessary to get these cases treated and cured has, 
with the poor record forms in use, made it impossible in 
most cities to discover how many cases of any one ailment 
were found, treated, or cured or how many children were at 
any given time or at the end of the year affected with a 
certain ailment. When the physician gives a list of "cases" 
we cannot tell whether these are the same which the doctor 
has found or new ones or how many of these "cases seen" 
represent a single child. A child with pediculosis may be 
seen several times by the physician and twice or three times 
a week for several months by the school nurse or janitress; 
yet there has been but one case or child. A case of defective 
vision may be seen once by the nurse or doctor and never 
again recorded. Until clear distinctions are made between 
these matters in more efficient reports, medical inspection (or 
supervision) will be on a hearsay, theoretical basis and there 
will exist both the greatest enthusiasm, and ungrounded 
belief in its wonder-working influence upon school and com- 
munity progress alongside of the greatest indifference and 
skepticism as to its utility. 

To obtain adequate reporting and accurate data, the ail- 
ments, new and old, found by the physician should be placed 
side by side with those found by the nurse in such a way to 
show exactly how many new ailments were found altogether, 
how often they were re-inspected and what was the outcome. 
It would be well if a plan could be devised whereby one per- 
son, the nurse, could do all the reporting on a single form.* 
In the following tables the work of the doctor and nurses 
for each ailment is listed together, but the distinctions men- 
tioned could not be made except for one or two cities. 

These facts should make us cautious about making dog- 
matic statements about the number of children affected with 
various ailments in these cities or the country at large. 



*See author's plan in the last chapter. 



no SCHOOL HEALTH ADMINISTRATION 

d. Doctors, for the most part, record only the cases that 
are printed on the record cards or report sheets. They will 
not, usually, take time to write in the names of the cases not 
named in the report. This has been proved in a number of 
satisfactory ways. It throws light not only on the following 
tables but on the kind of record cards and reports which are 
necessary to get the best results. They must give all the dif- 
ferent ailments and be very simple and convenient. The 
seventeen ailments making up 90 per cent of the cases found 
in all cities (Table IX) are not those appearing on record 
cards and reports. By the use of our classification of school 
ailments on the report forms, however, we can obviate the 
printing of a necessarily limited list of ailments on the 
individual record cards. 

e. Although school inspection by doctors was started by 
boards of health to keep down epidemics of infectious dis- 
eases through the exclusion of germ-carrying children, on the 
theory that the school was the chief, if not practically the 
only place of spread, nevertheless, comparatively few cases 
of infectious disease are found in the schools, and the amount 
of spread at school is seriously questioned. Mothers rarely 
are wrong in their interpretation of the children's condition, 
and keep the children at home so the ailments cannot be 
found at school. The first notice the school gets in the usual 
system is the report of the board of health on quarantine. 
Children are, however, sometimes found who have returned 
to school too early. The surprise is in the small number of 
cases found in school in proportion to the number which actu- 
ally existed. Table IX gives the actual number of ailments 
found, and the probable true number for the 54 classes of 
ailments. 

/. There is a great lack of correlation and integration 
among the various phases of hygiene in the school systems 
which have adopted medical inspection. The proper kind of 
organic unity will probably not come in the health work for 
most cities until a full-time physician, physical-educator is 
made director of all school health provisions. Only then will 
there be real supervision, careful work, adequate reporting, 



EFFICIENCY OF HEALTH WORK iii 

and testing of results. If this dissertation does no more than 
to emphasize this need it will have served a worthy purpose. 
Such a director can now be obtained at a salary of about 
$3,000, but the added cost need not be so great because in 
most cases one or more physical training teachers and several 
part-time physicians can be dispensed with. The recom- 
mended plan, as well as the needed number of directors, 
physicians and nurses with salaries (Table XII) is given 
later.* 

g. Very much dependence is placed upon the teachers in 
Inspecting the children for ailments and referring them to 
the doctors and nurses. In many cases it may almost be said 
that the chief function of the physician has been to remind 
the teachers to look for the ailments, when the bell was rung, 
announcing his presence In the building. Where there Is no 
annual routine inspection nor examination of all children the 
inspection has been more truly teacher inspection than medi- 
cal Inspection. So we shall find a teacher bias In the tables 
following. The need of Inspection of the teachers, and of 
their training in this work in their professional courses and 
In their classrooms Is very much neglected, to the great edu- 
cational and economic loss to schools and teachers. 

h. Teeth and such minor ailments are frequently given 
little notice by physicians, partly because their practice has 
omitted this element of health and partly because they find 
It of little value to record defective teeth when there is no 
school dental clinic or other adequate free agency for put- 
ting teeth In repair. Yet defective teeth are probably the 
chief source of many of the worst ailments of childhood 
and youth, not to mention later life. The words of the great 
Osier are familiar: "If I were asked to say whether more 
physical deterioration was produced by alcohol or by defec- 
tive teeth, I should unhesitatingly say by defective teeth." 

i. If the writer were asked which of the ailments In the 



*See also the article on this subject by the writer in the New 
England Journal of Education for Feb. 27, 1913, the address at the 
1913 N. E. A. convention and the address at the 1913 meeting of the 
International School Hygiene Congress. 



112 SCHOOL HEALTH ADMINISTRATION 

following tables had taken up most time of the doctors and 
nurses, which had actually absorbed most of the expenditure 
for medical inspection, he should unhesitatingly reply with 
the horrid word — lice. A child, especially a girl with her 
long hair, may be cured of this ailment a dozen times a term 
and still have it. One doctor on a comparatively very large 
salary spent most of his time during the year in going down 
the aisles of classrooms from the rear, using a small hand 
glass with which to spy out nits and other signs of vermin 
(pediculosis). His theory was that if children are taught 
to rid themselves of these larger parasites they will be better 
ready to accept the germ theory of disease and act upon 
it. The recent studies pointing to the larger parasites as 
the carriers of disease germs [the tick of spotted fever, the 
louse of typhus fever and perhaps other contagious diseases, 
not to mention the analogous work of the flea for bubonic 
plague or Black Death, the mosquito for malaria and yel- 
low fever, the stable fly (Stomoxys) for the infection of 
infantile paralysis (Poliomyelitis), and the house fly for 
various summer ailments, especially ravaging infancy], all 
would strengthen this point of view. 

While the theory is probably sound, the administrative 
question here Is : "Would it not be far more economical and 
just as good service if the city were to use the money to 
employ two nurses on full time for such work instead of the 
one part-time physician at $1,200?" 

Another interesting fact in this connection is that medical 
inspection was put into the school of one small town (South 
Manchester) in 1905 in the hope that the schools would 
soon be delivered of this parasitic plague (pediculosis) ; but 
even with the help of the nurse, the trouble has not been by 
any means eliminated, an irreducible minimum seeming to 
remain of those who furnish the parasites to others. The 
table shows a decrease in the number of children inspected 
as well as the number of times ailing, so the number has 
hardly decreased as rapidly as it appears. 



EFFICIENCY OF HEALTH WORK 113 

Total 
Number 

Pupils Cases of No. Pupils 

"Examined." Pediculosis. Excluded. 

First year 421 216 150 

Second year 458 282 I35 

Third year 477 227 125 

Fourth year 342 96 108 

Fifth year 318 84 89 

Sixth year 117 66 55 

"Examined" here means referred cases inspected. 
(Physical) examinations, one a year for each pupil, were 
begun in the year of this study. While there has been an 
increase in school population, there has been a decrease in 
cases reported and in the number of exclusions. It would 
be interesting to know whether the inspector has changed the 
meaning of "case" as time went on, and if standards of ex- 
clusion are not changing. The reports of this city should be 
followed up to see if the ailment is eliminated. 

GENERAL EFFICIENCY OF THE MEDICAL INSPECTION SERVICE 

Let US turn our attention first to the general accomplish- 
ment by the entire school medical service, and examine 
table VII which gives a bird's-eye view of this field. In 
order to separate unlike elements and to make clear what is 
actually being done, we have been driven to certain defini- 
tions which, we hope, may be of value not only for the 
purposes of this study, but also in actual school administra- 
tion. The first distinction is between Examination and In- 
spection, already mentioned: — 

a. Examination shall refer only to the complete physical ex- 

amination of a pupil by one or many persons, and re- 
corded on an individual, cumulative health record card 
for each pupil. The standard is one such examination 
a year, in this country, less often in Europe. 

b. Re-exatninationj or re-examined, shall refer to the vi^ork done 

by any person who duplicates any part of the physical 
examination because of a need for more technical ex- 
amination, because of doubt as to the reliability of the 
first findings, or for the purpose of checking up one or 
more of the first examiners. 

c. Inspection shall refer, when relating to pupils, to any partial 

examination, looking at, or study of a child or children 



114 SCHOOL HEALTH ADMINISTRATION 

with a view to learning the condition of their health, 
outside of the two forms of examination given above. A 
pupil should be examined thoroughly once a year, perhaps, 
but he may be inspected fifty or more times. 
d. Inspection, as a term, may be used also to refer to any 
study of school sanitation, home hygiene, or any other 
external feature. 

a. Examinations. Nearly every city that attempts com- 
plete routine examinations of pupils has provided an 
Individual, cumulative health record card for each pupil, and 
this definition will not exclude any city of the twenty-five 
that actually gives examinations. The work of examina- 
tion Is usually divided; and we find all agents from teachers 
to oculists making the vision examinations, and nurses, den- 
tists and doctors making the medical examinations, and 
hearing tests. Some, also, have physical-training teachers 
make certain measurements of height, weight, chest expan- 
sion, and the like; and have In each school, or haul about, 
platform scales with attached height standards. These lat- 
ter measurements are probably not worth the effort taken 
to get them. Doctors use other Indexes In making diagnoses, 
and the examinations as usually made with shoes and cloth- 
ing on are entirely valueless. The usual fate of such meas- 
urements, In the writer's experience, has been to fill physical 
training or medical inspection supervisor's offices with waste 
paper. As principal for several years, the writer made such 
measurements for an entire school, and found just one value 
In them : they could be used as a means of teaching the 
pupils the principles. Ideals, and habit of correct carriage 
and deep breathing. The best development of these anthro- 
pological measurements seen by the writer will be found in 
the 1910 and 1911-12 reports of medical Inspection In 
Dunfermline, Scotland. Even here they seem to have little 
pragmatic value and It Is significant that chest expansion 
measurements, given with doubt as to their value In the 
19 10 report, are not mentioned in the last. Here, we can 
only raise the problem. 

It seems the better and growing practice that nurses in- 
stead of doctors, teachers, principals, or physical-training 



EFFICIENCY OF HEALTH WORK 115 

teachers make the vision and hearing tests, where there is 
no school ocuHst for visual examination, or only for re- 
examination of actual cases as at Providence. The nurses 
can learn to make these examinations as easily as any of the 
other officials, and they have the several advantages of being 
the ones to get treatments, glasses, etc., of having a number 
of schools to examine in, thus giving more skilled practice 
and more uniformity, of being cheaper workers than phy- 
sicians, of doing the work without turning aside and being 
"bothered," as Is often the case with teachers, principals and 
physical-training teachers. States do well to have teachers 
do this work where there are no nurses; but cities and rural 
districts having nurses should, very probably, place the 
matter in their hands and give them training for doing It 
well. Oculists can be employed for re-examining the cases 
the nurses find and for prescribing glasses, treatment or 
operations for those who need them. 

Aurlsts can be attached to school clinics for the hearing 
and discharging-ear cases. 

h. Re-examinations . The nature of this process has, 
possibly, been clearly enough stated. It Is very little used. 

c. Inspections of pupils. These will be explained in 
detail in the tentative standard plan given later. Here it 
may be repeated that they are either routine or occasional 
inspections of all the children in rooms or schools for any 
general affections of a serious character, or for some special 
ailment such as pediculosis, infectious diseases, uncleanllness, 
and the like. 

Individual inspections are made of pupils referred to 
nurses and doctors by teachers, principals or parents; of 
pupils returning from over two or three days' absence or 
longer, either voluntarily absent, excluded, quarantined, or 
for any other reason; and of pupils entering the school for 
the first time, after the first two weeks or more of school. 
The September room-inspection, or such Inspection after 
each vacation or at the beginning of each term, will catch 
pupils entering in the first two or three weeks. 



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ii8 SCHOOL HEALTH ADMINISTRATION 

THE TABLE 

Turning, then, to table VII we see that only eight of the 
twenty-five cities have complete examinations; and that all, 
of course, have more or less of inspection. A city may have 
only inspections by doctors and nurses, and have vision and 
hearing examinations by teachers. The latter are only par- 
tial examinations, and are not always recorded on individual 
cumulative health record cards as described. Some do not 
have the complete examinations, and must, therefore, be 
classed simply as medical inspection systems in the narrow 
sense, and yet have the vision and hearing tests (partial- 
examinations) by nurses, teachers, doctors, or others. The 
strong tendency is, however, in the direction of the complete 
examination along with the inspection. 

Only one city seems to have examined all children in the 
school system, including the high school pupils, South Man- 
chester, although a few had some inspection in the high 
school. The Boston Board of Education employed a special 
physician (salary, $i,oo8) for the high school examina- 
tions, but no record was obtained of his work. In Newark 
and Jersey City the directors of the departments of medical 
Inspection examined a number of pupils in the high schools. 
The results are not included in this report of cases, or exami- 
nations. Summit began examining high school pupils in 
1912-13. 

The percentage of the enrolled elementary pupils medi- 
cally examined varies from about 42 per cent in Newark to 
100 per cent in South Manchester. The average for the 
eight cities (not including Syracuse, where we have only a 
record of work certificate examinations, by the Board of 
Health) is about 84 per cent. In Newark, the number 
would have been greater had more of the inspections and 
vision and hearing tests been made by nurses or teachers 
instead of by the doctors. (There were but eight nurses 
for the entire city with nearly sixty thousand elementary 
pupils.) The same may be said for Hoboken in part, for 
Rochester, Jersey City, and Meriden. 

The average number of pupils examined by each phy- 



EFFICIENCY OF HEALTH WORK 119 

sician, with and without the help of the nurses, varies from 
935 in Newark to 2,924 in Hoboken, with Jersey City not 
far behind (2,797). The doctors in Hoboken, however, 
were paid $100 a month instead of $30 and $40 as in 
Jersey City and Newark. They were required to give three 
instead of two hours a day as a rule, also. Other conditions 
being about equal, according to time spent, they should have 
50 per cent more examinations, and according to pay about 
three times as many. The number of inspections made in 
Newark, especially, is quite large, perhaps a reasonable 
number in Jersey City, while the number is not given in 
Hoboken, although the cases found by such inspections are 
given. Both Jersey City and Newark give also the number 
of room inspections, or "class inspections." None are given 
for Hoboken. Newark has given the doctors very much 
inspection to do, especially classroom inspection, and so gets 
fewer examinations. 

In Summit, the nurse assisted the physician at all ex- 
aminations and made 350 "examinations" herself. The lat- 
ter may have been only inspections. Where the nurse assists 
the physician at the examinations there are many advantages 
and few disadvantages: She learns a great deal of the 
science and practice of medicine, with a good physician, 
especially as related to the care of her school children; she 
learns just what ails each pupil and what would probably be 
the best ways of handling the different cases; she assists the 
physician greatly by making the vision and hearing examina- 
tions, getting the children ready for the examinations by 
calling them from their rooms, calming their fears, keeping 
them in control, getting them washed if necessary, removing 
or loosening part of the clothing, etc. ; she frequently helps 
to make all of the records, reports, notices, and the like; 
she gets the physician's advice immediately regarding any 
part of the examination she is making and over which she 
is puzzled; she frequently observes, from her own experi- 
ence, certain defects or ailments which the physician may 
overlook; and last, but not least, she learns to know the 



I20 SCHOOL HEALTH ADMINISTRATION 

abnormal child with respect to the normal child as a 
standard. 

In Summit, one school has an exceptionally fine medical 
supervision room — large, well-lighted, even if in a partial 
basement, and fairly well equipped with tables, desks, hot 
and cold water, screens, a couch, medical cabinet, etc. It 
is probable that the nurse and physician working together 
as a team in the complete examinations of pupils can examine 
better 125 pupils in the same time it would take them 
separately to examine 100 pupils. No exact figures are ob- 
tainable on this problem. I know of no special disadvan- 
tages of such teamwork examinations. In Montclair, each 
school has a janitress, as well as a janitor, and these women 
are unusually helpful in all examinations and inspections, 
saving very much time for all concerned. They even give 
the treatments for pediculosis. 

NUMBER OF EXAMINATIONS 

Only 125 daily visits about an hour, on the average, in 
actual medical work with pupils (not counting travel to and 
fro) were made by the physician in Summit. How many of 
these were visits when only inspections were made we are 
not told; we judge from the report of many calls, probably 
25, leaving 100 for examinations of 1,034 pupils. For, 
say, 170 daily visits of two hours each and with the assist- 
ance of the nurse, and with not a great many inspections to 
make, we should expect the physician to make (100 is to 2 
times 170 that 1,034 is to ?) or 3,515 examinations, say, 
3,000 annually. With a good deal of the inspection of 
referred cases to do, this 3,000 would probably be the maxi- 
mum number annually. Here, however, the nurse was also 
attendance officer, throwing more inspection to the doctor. 

Jersey City physicians, working, according to the rules, 
two hours a day and making the vision and hearing tests, 
and without the continuous help of the nurse (6 nurses to 
12 doctors) and with the same average number of individual 
Inspections, besides 936 class-room inspections, report almost 
the same average number, 2,797, doing better, probably, as 



EFFICIENCY OF HEALTH WORK 121 

to quantity than any other city. We cannot judge as to the 
quahty of these examinations, of course. 

In Trenton, the doctors, without much help from the 
nurses, except for vision testing, report an average of 1,323 
examinations, and 1,047 inspections in 89 visits, on the aver- 
age, of not much over an hour each in actual school medical 
work. The school year was 196 days. Counting only 170 
daily visits again, we should expect at this rate from each 
physician giving the same time as now (89 is to 170 that 
1,323 is to ?), or 2,250 examinations, and almost a propor- 
tionate number of inspections. For twice the time, which 
on the average would probably not exceed two hours, we 
should have 4,450 examinations. Then 3,000 would seem 
to be a minimum number, at least a very reasonable number, 
especially since we have deducted no days from the 89 for 
mere inspection visits. 

At Rochester, for which we have the number of daily 
visits but do not have the average number of hours a day 
for each physician, our estimate, given in another table, is 
one hour. At any rate, an average of 170 visits is given, 
but how many mere inspection visits we do not know. The 
highest number of examinations reported is 2,334 and the 
lowest by a regular examiner (180 by a specialist) is 484. 
The median is about 1,550. Since we have the figures, this 
is a better figure perhaps than the average because of the 
wide variation. For twice the time we should again expect 
over 3,000 examinations as a median performance, and with 
nurses making the vision and hearing tests and helping at 
the examinations and making more inspections (only three 
nurses for the city), we should expect 4,000. So 3,000 
here for two hours a day seem not to be unreasonable. 

Merlden physicians made an average of 1,207 complete 
examinations without a nurse's assistance (only one nurse 
for the city) after the first of November when the system 
got started. For ten months the number could probably 
have been 1,500. They averaged probably an hour each 
day. For twice the time, and with no re-examination of 
defective vision cases reported by teachers (leaving this to 



122 SCHOOL HEALTH ADMINISTRATION 

nurses) and no measurements, we see that probably 3,000 
pupils could easily have been examined during the school 
year, and twice as many inspections made by each doctor. 

Perhaps experience will show that desirable improve- 
ment in the quality of examinations will force a reduction to 
a lower maximum than 3,000. Ohio has been discussing a 
state law for this maximum number for physicians and efforts 
have been made to make the number 2,000. Careful ex- 
periments have not yet been made which will make possible 
any dogmatism. Lack of funds requires a large number of 
pupils for each examiner, to start with. And if three thou- 
sand can be examined by one man it will be desirable. 

VISION AND HEARING TESTING BY TEACHERS, NURSES AND 

OCULIST 

These tests were all made by the teachers in Massachu- 
setts and Connecticut, and to some extent in Providence. The 
records are unsatisfactory. In Massachusetts the examina- 
tions are made annually. The rules for Meriden, Conn., 
were as follows: 

"Teachers shall make the vision tests and the proper 
records in connection therewith in September, or whenever 
they may enter, for all new children above first grade; in 
February for all children in first grade; and once in three 
years for all children. Tests may be omitted in the kinder- 
gartens." 

Teachers reported all children with vision 20/40 or 
worse, and pupils with even better vision but with evidences 
of eyestrain, headaches, etc., to the doctors, and no others. 
The latter re-examined the pupils, and had the nurse send 
out messages. Had the re-examination been made by a 
school oculist and prescriptions given it would have been 
better. 

The stop watch and whisper tests are chiefly used to test 
hearing. Groups of children are often tested at a time 
In this manner. The common test is whether the pupil can, 
with each ear and without seeing the lips, hear distinctly 
low spoken words or sentences at a reasonable distance. No 



EFFICIENCY OF HEALTH WORK 123 

attempt of which I know has been made to use the audio- 
meter. Probably nearly all cases are found with little 
trouble in the present manner. Efforts should be made, 
however, to standardize and make objective the meas- 
urement. 

The number of pupils tested for vision in proportion to 
elementary school enrollment varies from zero in Mt. Ver- 
non and Syracuse up to a hundred per cent in four cities. 
Hoboken, perhaps, made more tests than are recorded by 
the nurse. 

Where the nurses tested for vision or hearing or both, 
we are interested in the average number, for such tests take 
up considerable time. We know the facts for only one city, 
without qualification. Trenton's two nurses made on the 
average 3,245 vision tests each. Their other work seems 
to be little less than that of other nurses. 

EXAMINATIONS 

We have seen that the number of examinations may well 
be nearly 3,000 for two hours a day, five days a week, the 
nurse making vision and hearing tests and measurements, if 
possible, the nurse assisting at the examinations, and the 
work lasting through the school year. 

This may be seen to be a probably reasonable number 
by beginning at the other end, the number of examinations 
in an hour. With no other work, and the nurse and doctor 
working as a team, and with simple records, at least ten 
pupils can be examined as a reasonable number, in an hour, 
twenty in a two hour period. 

Without many individual inspections, this would be in 
185 school days, 3,700 pupils for each doctor with a nurse. 
Counting off for all forms of inspection, but placing the 
burden of it upon the nurse, we see again coming out the 
estimate of a reasonable maximum number, perhaps, of 
3,000 pupils. 

In the long run, it seems best to give to nurses the vision 
and hearing testing. How often these should be made is 
doubtful, probably not as often as once a year for all pupils, 



124 SCHOOL HEALTH ADMINISTRATION 

as a matter of routine. In Europe, the complete examina- 
tions come only three or four times in a course of eight 
years. The Meriden intervals are recommended for con- 
sideration. Probably every other year would be wise. 

In Newark and several cities, the children with 20/30 
normal vision are recorded defective and referred. The 
more universal and desirable practice is to follow the Eng- 
lish and Massachusetts plan given, referring only those 
20/40 or less, unless they have other symptoms of eyestrain 
or other eye defects. 

The Massachusetts' rules for hearing, quite generally 
followed, give 25 feet in a still room as the easily heard 
"standard whisper" (if there is such a thing), 35 to 45 
feet for a low voice, and 45 to 60 feet for a loud voice. 
Most medical rooms in schools, or the places assigned to 
doctors and nurses in old buildings are very poorly adapted 
for such work. Halls are frequently used to give the desired 
space. 

INSPECTIONS OF ELEMENTARY PUPILS 

We can hardly discover the number of inspections of 
the different kinds. The doctor at Waterbury reports as 
many as 250 inspections an hour. This is by class-rooms and 
principally pediculosis and infectious disease inspection. Dr. 
Mercelis of Montclair estimates 50 children an hour as a 
reasonable number to inspect by rooms. Individual inspec- 
tions are, of course, scattered over days and weeks, and prob- 
ably take from one to five minutes each. As we glance down 
the columns, we see that Waterbury and Syracuse are count- 
ing room-inspections as individual inspections. Newark and 
Jersey City are the only cities giving the number of indi- 
vidual and the number of room-inspections separately. 
Several give only the individual inspections referred to them 
by nurse and teachers. Room-inspections should be recorded 
by rooms rather than by the number of individual pupils 
in them. 

Boston included a parochial group of children, but the 
average is about 7,000 children inspected for each doctor. 



EFFICIENCY OF HEALTH WORK 125 

How many room inspections are in this we could not learn. 
It is an average of over 40 a day for 170 days, probably 
more than any physician served. 

Yonkers' physicians made no examinations and averaged 
for the two, 7,437 inspections each. How many different 
children this represents we do not know. Any pupil may 
have been inspected many times in a year. There were only 
71 school-visits (one school, one visit), with sometimes two 
or three schools in a day. Unfortunately, the number of 
daily visits was not kept separate. But even counting it as 
71 school visits, the average number inspected at each 
school visit was somewhat over a hundred. 

Since we obtained from the reports, the facts regarding 
the number of times different schools were visited in Yonkers 
by the two physicians, and since the Superintendent has 
characterized each one for us, we give here these data : 

Six schools visited only once during the year, mostly small 
country schools. 

Four schools visited only twice during the year, partly 
small country schools. 

Three schools visited only three times during the year, 
two in rich districts. 

Two schools visited only four times during the year, one 
rich, the other rural. 

One school visited only five times during the year, aver- 
age, city. 

One school visited only seven times during the year, large 
and poor. 

One school visited only eight times during the year, large 
and poor. 

One school visited only nine times during the year, large 
and poor. 

One school visited only eleven times during the year, large 
and poor. 

In sum, 20 schools visited only seventy-one times during 
the year, by the two physicians. 

The average number of school-visits for the 20 schools 
is less than 4 for each school, and ten or half of them were 
visited less than three times, in 185 days of the school year. 
The city had only one nurse to assist the doctors. The 
enormous number of cases In proportion to the number of 
doctors and nurse (given in a later table) shows a need, 
probably greater than for any city visited, of an enlarged 



126 SCHOOL HEALTH ADMINISTRATION 

force. (Yet the writer was told that Yonkers was a wealthy 
city and needed little such work.) One school with 23 and 
another with 27 teachers besides the principals were visited 
but three times each, and another school with 25 teachers 
was visited but twice. 

In Brockton, the small number of inspections by doctors 
is due to the fact that in this city the physicians are used 
only for consultation over puzzling cases, by the nurse. An 
average of 436 cases each is thus recorded. There was but 
one nurse for the entire city. One of the physicians is on 
the Board of Education, and donates his services. The 
work here shows what nurses may do alone if properly 
supervised. Oakland, California, has a large force of nurses 
with one full-time directing physician ; and the system seems 
to work well. No one is on part-time. Pupils fail to get 
the same number of skilled routine examinations in such a 
system, but the puzzling cases may be re-inspected for the 
nurses ; and probably nearly all real ailments may be found. 

The median number of individual inspections, throwing 
out room-inspections which should be counted by rooms as 
in Newark and Jersey City (rather than by the number of 
pupils in them), is probably not far from 3,000. With the 
system devised as given for examinations, this number could 
probably easily be raised to 5,000, not counting room-in- 
spections, of which there would be for each physician (3,000 
pupils, divided by 40) 75 in the routine September room- 
inspections. 

In Jersey City, the average number of rooms inspected 
for each physician was 78, and in Newark (counting an 
average of 26 physicians), 383, or an average of two or 
three a day. This large amount of room-inspections in 
Newark probably accounts for the small number of exami- 
nations. The average number of individual inspections is 
also large, over 8,000. Most of this inspection work could 
be placed in the hands of nurses at about half the salary 
per hour with probably better results, since the work is rela- 
tively simple when once learned, and since the nurse must 
follow up the cases anyway. 



EFFICIENCY OF HEALTH WORK 127 

The grades in which most inspection, probably eighty 
per cent, is done are the first three or four. Most inspectors 
wisely emphasize this age period not only because there are 
many more cases, but because of the greater number of 
serious diseases and deaths at this age and the desirability 
of nipping pathological tendencies in the bud if possible. 

INSPECTIONS BY NURSES 

The number of inspections by nurses is given in the next 
columns (65 and 66). They range upward from practically 
zero, where nurses spend their entire time following up 
cases found by physicians. Several of the cities, especially 
those with board of health control of this work are in or 
very close to this class. We need not specify, because in most 
cities even nurses so restricted would probably find a num- 
ber of cases without making any inspections (searches) for 
them in the schools. In the list of ailments given in a later 
table the fact that nurses in any city report more cases than 
are reported by the doctor and possibly referred to them 
would indicate, where she has not met the same case a 
large number of times, that they were probably finding new 
cases themselves. A great weakness in the reporting lies 
here. It is impossible to discover how many new ailments 
were found by both doctors and nurses, and how many were 
merely referred from the former to the latter. The term 
"case" should be avoided in all reports, "ailments" and 
"children" are better, since a "case" may mean several dif- 
ferent ailments. 

The nature of the report, or the lack of a report, on 
this item leaves a blank record of inspections for the nurses 
of twelve cities. The reporting for nurses is so relatively 
new that we should expect the emphasis to be placed in 
reports upon the work of the physician. Most nurses here 
probably deserve much better reports than they made or re- 
ceived. The large average figures in Brockton, Schenectady 
and Syracuse mean a large number of class-room inspections 
where the number of pupils rather than the number of 
rooms was recorded. But the record of Newark is ex- 
traordinary, for not only were there an average of 20,000 



128 SCHOOL HEALTH ADMINISTRATION 

individual inspections for each of the eight nurses, but there 
were an average of 493 class-room inspections each, and an 
average of an extra 750 inspections for uncleanliness each. 
This, with an average of 1,118 home visits would seem to 
place the amount of work done by each Newark nurse far 
ahead of all others reporting. This is very probably due to 
an excellent administration of their work as well as to 
adequate reports and faithful performance of duty. How- 
ever, it is difficult to make accurate comparisons. 

For Trenton we give the number of inspections by a new, 
and by an experienced nurse, the latter making 2,477 '^^' 
spections to the other's 993. The more experienced the 
nurse in this work the more of the service of inspections can 
be given her. 

Were we to divide the average of 41,205 pupils in- 
spected by each nurse in Schenectady by an average sized 
class, say 40, we should have a figure nearer the general 
tendency. Were we to allow for 5,000 individual inspec- 
tions we should still have 900 room inspections each. At a 
half hour each, these would amount to 90 school days of 5 
hours each. In Brockton, the 17,365 inspections (called 
"examinations" as they are in most cities) were as follows: 
throat inspections, 7,589; re-inspected (general), 605; in- 
spected (general) next term, 7,971; re-inspections at office, 
600. As before related, 1,309 were also re-inspected by the 
doctors. 

The median number of individual inspections for each 
nurse, W/orking 35 to 44 hours a week, is probably near 
4,000. How many class-room inspections can be added to 
this depends upon the amount of home visiting and the 
character of the supervision. First-class supervision means 
in general first-class work. Lack of, or poor, supervision 
generally means work of uneven quality and a low general 
average. 

The range of inspections is from 946 in Mt. Vernon, all 
probably actual ailments referred by doctors and teachers, 
up to the large numbers named. 



EFFICIENCY OF HEALTH WORK 129 

What would be a good standard for a nurse with the 
plan mentioned would probably not be far from ; 

4,000 individual inspections Newark nurse 20,000 

200 class-room inspections Newark nurse 493 

1,000 home visits ^. .Newark nurse 1,1 18 

500 treatments, by the nurse Newark nurse 5,623 

300 taken to dispensary or physician Newark nurse 108 

3,000 examinations, assisting the ph}'sician. . .Newark nurse ? 

The examinations witii the physician would take prob- 
ably one-fourth of the time. After school, before school 
and on Saturday mornings the home visits and part of the 
dispensary visits could be made. In the remaining three 
hours of each day, the inspections and treatments could be 
given. On the right, in the statement above, are given the 
average figures for each nurse in Newark. They are far 
ahead in all but dispensary visits and assisting at examina- 
tions. If possible, the standard of number of treatments 
by the Newark nurses should be equaled. Treatments by 
the nurse should, however, be separated from treatments by 
others outside of the schools. Nothing less than this and 
school clinics will effectually root out or keep down a very 
large number of bad filth and infectious ailments. Newark 
has gone far ahead of all cities in the treatment of these 
minor ailments of the poor, ignorant and needy, at least so 
far as records go. Without such treatment, the expensive 
system quite largely fails to function, even though, as in 
Newark, a great many treatments were made by outside 
agencies, such as hospital dispensaries, private physicians, 
dentists, oculists and parents. 

PERCENTAGE OF ELEMENTARY SCHOOL POPULATION 
DEFECTIVE 

It is again very difficult to learn the percentage of pupils 
defective, because cases and not children In many instances 
are reported. The approximate numbers so far as could be 
learned by much patient delving and inquiry are given in 
column 69. The percentages in the next column show the 
proportion of the elementary school population affected. 
The cases below 22 per cent are not representative and 



I30 SCHOOL HEALTH ADMINISTRATION 

simply mean that the cases were not found, the inspections 
being limited almost entirely to infectious ailments in certain 
cities, as can be seen from the table of ailments found. The 
six cities below 50 per cent could all be explained in this 
manner. Hoboken alone, probably, has an unmerited low 
standing. The facts could not be learned from the reports. 
The eleven cities with no percentages would probably show 
a similar range as the fourteen given. The highest per- 
centage given is 66 per cent and this Is doubtful, because of 
the confusion as to cases, ailments, and children. Newark's 
report is definite on this; and 60 per cent seems to be near 
the truth. 

But most ailments are teeth defects, percentages ranging 
up to 90 frequently being given for the number of children 
so affected. Many children are In good health with but this 
one exception. Leaving out such children with the great 
people's disease, we have a series of ratios (column 70) in 
the more representative cities hovering around 30 to 35 
per cent. We should probably be quite safe In prophesying 
that one out of three of all the pupils In a school system are 
each year at some time seriously ailing or defective, not 
counting defective teeth and about twice this percentage If 
teeth are counted. Roughly, a third have no serious ail- 
ments, a third have only teeth defects, and a third have teeth 
defects and some other ailments or defects. We dare take 
neither the space nor the time here to compare m detail 
these results with those of other Investigators. The New 
York percentages for 191 1, with 230,243 pupils examined, 
are quite similar, only larger In defectiveness: 

New York 
My General Estimate. Results, 191 1. 

With no ailments 33 per cent. 27 per cent. 

With only defective teeth 33 per cent. 39 per cent. 

With D. T. and other ailrnents. 34 per cent. 34 per cent. 

The likeness Is striking, and shows the conditions of child 
health In the various cities to be probably much more nearly 
similar than are the doctors' reports. The general per- 
centage for defectiveness in the whole elementary school pop- 



EFFICIENCY OF HEALTH WORK 131 

ulation, taken together, and greater in the lower grades, is 
about 67 per cent; for New York City it is 74 per cent. 

If this standard is fairly accurate, dividing the ele- 
mentary school children roughly into three equal groups 
(good, fair, bad) we can use it as a measuring rod for de- 
termining both the health problem of medical supervision 
and how cities are meeting it. 

We can say, for example, that systems which find less 
than forty per cent of the pupils with defective teeth, prob- 
ably are not examining carefully for decayed teeth, reach 
only a part of the school population, or have had a wonder- 
ful crusade of dentistry. 

A number of the cities named fall far below these 
standards. Eleven cities do not give the facts from which 
to judge. 

Likewise we can say that cities finding enormous per- 
centages of defective teeth, for example, probably have their 
standards for defectiveness too low, so, too many are 
counted; or that the city is just beginning the work (if this 
really makes much difference), or that here we have a fac- 
tory town with much poverty, ignorance and immigrants. 

Whether the standards stand the test of time or not, the 
value is in the beginning of such standardization of school 
health procedure. We hope the percentages of defective- 
ness may be greatly lowered. Later chapters derive tenta- 
tive standards for each ailment, and group of ailments. 

CURES AND IMPROVEMENTS OF AILMENTS 

The function of medical inspection (or of medical su- 
pervision) is not only to find, but to promote the cure and 
prevention, of pupils' ailments. The emphasis should be 
strongly upon the side of cure and prevention. Prevention 
is so much a social and economic, as well as a school prob- 
lem, that we may be pardoned for a while in concentrating 
upon cures, until our studies lead us back into those funda- 
mental methods of prevention such as educational, economic, 
and eugenic reform. To get cures there must be treatments. 
We have recorded all the treatments by nurses alone, and by 



132 SCHOOL HEALTH ADMINISTRATION 

other agencies, in separate columns (cols. 71 and 72). 
They are not accurate, because the two forms of treatment 
are frequently confused or reported together, or the records 
are poor or misleading. That nurses should succeed so well 
in getting all these thousands of treatments in one of these 
early years of a great movement, is occasion for great praise 
and satisfaction. We are sure that many more in the blank 
spaces would make fair or good showings had we the facts. 

But how many defective children, or what percentage of 
the ailments received treatment? The data hardly permit 
a guess. Newark records more than twice as many treat- 
ments as children ailing, and three-fifths as many cures as 
children ailing ("cases"). The number of cures is larger 
than the number of children defective; and this is quite nor- 
mal for the average number of defects to a child is about 
two. We must find the number of new ailments rather 
than the number of children defective in this problem, and 
relate it to the number of ailments treated and cured. 

The number of ailments found is given in another 
column (82). After it comes the number referred, showing 
that some cities record many minor ailments which they do 
not set out to get cured. It were better that they remain 
unrecorded, it seems. Until cities list for each ailment treat- 
ments and cures, this problem of percentage of cases treated 
will remain unsolved. Later we shall show that favus cases 
in Dunfermline were treated in the school clinic in one year 
on the average 94 times; so we have complicating features. 
Newark's data would give the facts except that the exami- 
nations covered less than half of the elementary school 
population and the inspections covered all. Judging only 
from the total number of ailments or children ailing found 
by the examinations we should say that 60 per cent were 
cured. But there were cases (ailments) found also by the 
doctors in inspecting children not examined, those who had 
been examined earlier in whom new ailments had arisen, 
and also new cases (ailments) by the nurses not found by 
the physicians and referred to them. When we have the 
sum of all these new cases (ailments) and then the sum of 



EFFICIENCY OF HEALTH WORK 133 

all cures, we can arrive at general conclusions as to efficiency. 
In some way we must know the total number of children 
afflicted and the number of ailments these children had and 
what was done with them. 

What the form of reports should be in this field we shall 
attempt to work out in a final chapter. 

The efficiency of the nurses is not adequately shown in 
these figures of treatments, cures and improvements. Ex- 
perience in Philadelphia and elsewhere has shown over and 
over again that parents respond to only about five or six 
per cent of the notices of children's ailments without the 
assistance of the nurse. With an adequate force of nurses 
and good backing, they will probably raise this percentage 
up to fifty per cent or more. If doctors were more con- 
servative about referring ailments this percentage would 
be raised still higher, quite legitimately and easily, perhaps 
up to eighty or more per cent. Better concentrate all 
energies on the worst cases, than to disgust parents and 
family physicians with notices of trivial ailments. "The 
doctor sent us home a notice that my little sister was too 
tall for her age," said one young lady to me. "What does 
he expect us to do to her?" 



See the comparison of results of work of doctors and nurses for 
different ailments and for different social grades of population given in 
the pamphlet entitled "Medical Inspection of Public Schools, Philadel- 
phia, 1913," printed by the Board of Education for the Fourth Inter- 
national Congress on School Hygiene. The charts show that parents 
iseem to be responding better to doctors than formerly, but that the 
jiurse is indispensable. 

Further efficiency tables will be found in Chapter Nine. 



CHAPTER SIX 

THE AILMENTS OF PUBLIC SCHOOL CHILDREN 

A. PHYSICAL DEFECTS 

THE AILMENTS OF PUBLIC SCHOOL CHILDREN IN 25 CITIES 

The Classification of School Ailments 

The first and most difficult problem connected with a 
comparative study of the work done by doctors and nurses 
as reported in these twenty-five cities has been that of mak- 
ing a simple, working classification of the ailments of school 
children. Several hundred different names for the various 
ailments occurred in the various reports; many names for 
the same ailment were used; and no one classification or 
system of nomenclature seemed satisfactory. The word 
"ailment" here is used to cover all defects and diseases, and 
seems preferable to the term disorders used by Dr. Hoag, 
although the latter serves the purpose. 

There are a number of classifications of human ailments 
but their bases are all pretty largely that of their death- 
dealing character and the parts of the body affected. There 
is, for example, the International Classification of Diseases 
and Injuries, the Bellevue Classification (Bellevue Hospital, 
New York City), the classification used by the U. S. Mor- 
tality Statistics, and the various classifications used by local 
and state boards of health. They are really classifications 
of the direct causes of death. One of the first distinctions 
here is the fact that the ailments most affecting school chil- 
dren and school work are quite largely not death-dealing. 
The proportion of ailments from which school children die 
is a very small share of the total found. As can be seen at 
the end of the table, columns 214 to 217 and 210 to 211, 
the deaths of children of school age in each city are very 

134 



AILMENTS OF SCHOOL CHILDREN 135 

few in comparison with the number of cases of disease and 
these of ailments which occur comparatively infrequently. 
Moreover, the recorded school ailments are not all occurring 
in the age population, 5-19 inclusive. The classification of 
ailments here must be a school classification. 

The problem then became a choice of names, or terms, 
and of division, or classification, in the logical sense. The 
classifications finally devised were one based upon the loca- 
tion of the various ailments such as is used by the Boston 
Board of Health, and a simpler classification, on a more 
pragmatic, educational basis. These two classifications were 
duplicated and sent out to a few nurses, medical examiners 
and supervisors of medical supervision with the result 
that the location-basis classification was rejected. There 
were too many divisions; and after such a classification is 
completed, there always appear ailments which must go into 
a miscellaneous group almost as large in some cases as the 
well-classified portion. We have a miscellaneous group in 
our tables largely because of ailments recorded only as 
"miscellaneous" in the reports. 

The classification finally adopted and here offered for 
criticism is as follows : 

I. Communicable Ailments. 

A. Parasitic and Minor. 

B. Infectious Diseases. 

II. Non-Communicable Ailments. 

A. Physical Defects. 

B. Common Ailments. 

The work of placing the many terms used for the vari- 
ous ailments under a few (54) rubrics was done with the 
help of the following texts: 

a. Holt's "Diseases of Childhood and Infancy," Ap- 
pletons. 

b. McComb's "Diseases of Children for Nurses," W. 
B. Saunders Co. 

c. Hoxie's "Practice of Medicine for Nurses," W. B. 
Saunders Co. 



136 SCHOOL HEALTH ADMINISTRATION 

d. Ditman's "Home Hygiene and Prevention of Dis- 
ease," Duffield & Co. 

e. Cornell's "Health and Medical Inspection of School 
Children," F. A. Davis Co. 

f. Hoag's "The Health Index of Children," Whitaker 
& Ray-Wiggin Co. 

g. Medical Dictionaries. 

Some of the practical considerations which have in- 
fluenced this selection of terms have been the following: 

a. The names of ailments actually used most commonly 
by school doctors and nurses. 

b. The names which would be most easily understood 
by the parents and citizens to whom reports are supposed 
to be made. 

c. Grouping the ailments according to the divisions of 
the work. Nurses have almost exclusive control over 
parasitic and minor infectious ailments, for example. 

d. Emphasizing important and often neglected ailments 
and divisions of ailments by position. This accounts for 
placing the word "dental" before "teeth," for example. 
Important divisions and ailments are placed high in the list 
when possible. 

e. The number of ailments which would be an optimum 
number upon which to report, taking into consideration the 
many practical exigencies. 

For certain of these reasons the division of non-com- 
municable ailments is placed first. These ailments are prob- 
ably most important for school life, especially physical de- 
fects. Diseases which occur very infrequently or have little 
effect upon school life are omitted, blank places being left 
after each group on our report for writing in these, if found. 
(See final chapter.) We recommend that an N. E. A. 
committee be appointed to further condense and standardize 
the classification. 

The reader should examine the complete classification 
given in the last chapter. 

All classifications are compromises and are to be judged 
by the service they render. The many faults in this clas- 



AILMENTS OF SCHOOL CHILDREN 137 

sification are probably obvious, but it serves our present pur- 
pose of displaying in convenient form the ailments found, 
and may be of value in bringing about a more serviceable 
one for the use of schools. At present there is practically 
no genuine and satisfactory classification in use by any 
schools. 

ANALYSIS OF TABLE VIII 

One of the first tables made by the author was an at- 
tempt to show the number of cases found by doctors and by 
nurses and the number of ailments treated, improved and 
cured. Such a table, while offering the possibility for needed 
data, was very cumbrous and was conspicuous for its vacant 
spaces, the data not being given by enough cities to count 
for much. In the table as here offered, there are three 
columns each for only six physical defects; the ailments 
found by the physicians, by the nurses, and the number 
treated, cured, or found treated or cured. For the most 
part the ailments found by the physicians are referred to 
the nurses, especially where parents do not respond within a 
given time (and, to repeat, only about five or six per cent 
of parents do respond to physicians' notices without the 
nurses' visits) so the sum of the doctors' and nurses' cases 
would not be the true total of ailments. Every ailment, too, is 
not a new ailment. In certain cities, and for certain inspectors 
and nurses within cities, every time a child is seen for a 
given ailment we get a record for another "case," ailment. 
This helps to account for some of the large sums and, pre- 
sumably, very bad morbidity found in certain cities. Where 
we find a record of very many more cases of an ailment 
found by nurses (See adenoids in Cambridge, New Bedford, 
Brockton, Winchester) than by physicians we may be sure 
that here the sum given by the nurse represents nearly all 
the ailments. These difficulties with double reporting seem 
also to point to the nurse as the one to make the only and 
complete reports of medical supervision. The record shows 
In general the total number of cases found by doctors, re- 
ferred to the nurses, and "seen," treated, procured treat- 
ment for, or found treated, by later inspections by teachers 



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I40 SCHOOL HEALTH ADMINISTRATION 

or nurses. The nurse's column shows, then, for the most 
part the cases which the nurses themselves treated or tried 
to get treated and cured through the homes or other 
agencies. There are many excuses, of course, for the poor 
showing which many cities make on this chart, through the 
absence of better reporting. For a board of health with 
long experience in the health field, and with a system of 
medical inspection organized for several years, there is, 
however, hardly any good excuse. For five of the cities, the 
writer made the summaries of the doctors' and nurses' re- 
ports for the year studied. (Norwood, Montclair, Water- 
bury, Yonkers and New Bedford.) For several others, 
partial summaries were made, as for the nurses of Trenton. 
This partly accounts for the greater detail of the records for 
these cities. Most of these cities have since printed sum- 
maries of this work and it has been interesting and instruc- 
tive to get from these what such a report may mean, and 
how much it may vary from the real work, and the monthly 
and weekly records. The protracted and tedious labor of 
making such summaries for a year, especially where there 
were weekly reports from a number of doctors and nurses, 
gave some valuable insight into what good reporting 
should be. 

Some cities, like Jersey City and some of the board of 
health cities, reported only, or practically only, the excluded 
cases, children so afflicted that they were sent out of school. 
Such cases are, of course, but a small percentage of the 
actual number, and such reports are of little value educa- 
tionally. The efficiency of medical inspection cannot be 
measured or recorded by such meager data. As they stand, 
the records require interpretation city by city and almost 
item by item, so many deductions of scientific exactitude 
cannot be drawn from them. It will be necessary later to 
take good records of several cities and make a special study 
of them. 

Another thing which must always be kept in mind in 
looking over such reports is that many of the ailments listed 
are only "suspected'^ ailments. This is especially true of 



AILMENTS OF SCHOOL CHILDREN 141 

infectious diseases, adenoids and any other ailments which 
are difficult of diagnosis. The children are referred to 
family physicians, clinics and dispensaries for more careful 
diagnosis and treatment. This lack of final responsibility 
for an ailment sometimes makes school medical workers 
careless. The writer has seen many children recorded as 
having ailments, adenoids or enlarged tonsils, for example, 
where, from his own study of medicine, and experience in 
schools, hospitals and dispensaries, there were no such ail- 
ments — the enlargement being quite normal, at least not 
pathological enough to require attention or treatment. Such 
cases are so frequently reported "negative" by family phy- 
sicians as to disgust the parents and make the best results 
hard to obtain. Exclusions, too, are in most cities far more 
frequent than necessary. Every city should have such su- 
pervision of this work as will adequately review the inspec- 
tions, examinations, exclusions, etc., and hold physicians 
and nurses as strictly responsible as the nature of the work 
will permit. Nurses seem more careful than doctors, since 
they must follow-up the cases. 

A. PHYSICAL DEFECTS 

I. Adenoids. Some cities report only "Obstructed 
Breathing" for this defect, because physicians find it desir- 
able to report the symptoms without making a manual ex- 
ploration which frequently hurts and frightens the children. 
The medical phases of this work are so well treated by 
Cornell in his text on "Medical Inspection," referred to 
before, and in other texts, that only some of the administra- 
tive problems will be discussed, for the fifty-four ailments, 
in this place. Of the 12,652 adenoid cases reported by 
physicians and the 9,311 found or seen to by nurses, cer- 
tainly many more than the 1,993 given were treated or 
found cured on re-inspection. However, some cities make 
the mistake of taking the teachers' reports as to cures. No 
ailment should be counted "improved" or "cured" which 
is not found so by competent re-inspection, or checking-up- 
inspection, by the doctor or nurse. Such obvious cases as 
the wearing of glasses after vision has been reported de- 



142 SCHOOL HEALTH ADMINISTRATION 

fective, even, should be handled in the same way. The 
glasses may not fit. This, in general, is an administrative 
fact purchased very dearly in experience in a number of 
progressive cities. 

There were also more cases of adenoids and nasal ob- 
struction found than are here reported. Several cities have 
no records of this important school ailment. Meriden prob- 
ably found many cases but for some unknown reason they 
were not given in the report. 

Our interpretation of the Summit report is that there 
were 38 cases in all found, but no report was made of those 
operated on, or treated. The same is true for Norwood: 
i 9 cases found, no record of cures, although the nurse did 
take a number of children to the free clinics of Boston for 
operations. For Winchester, no cases are reported by the 
physician and 80 are reported as found and 62 as cured by 
operations, by the nurse. The report here is in this form: 
"Operated upon for tonsils and adenoids. . . .62." We can- 
not be sure that all were operated on for both adenoids and 
tonsils though this method is quite general, since the two 
ailments are very closely associated. For reporting, how- 
ever, the two should be separated, since it is only a matter 
of convenience that both operations take place at once. The 
report would be better in this form using the terminology 
of the report, "Mouth breathers," 80; operations, 62 ( ?) ; 
negative, — ; not treated, — . Enlarged tonsils, 138 ; opera- 
tions, 62 ( ?) ; negative, — ; not treated, — . 

Although we have only about six or seven scientific 
studies of the relation of school defects to school progress,* 
and consequently cannot assert any more than that adenoids 
and nasal obstructions have very serious effects upon health 
and school progress, it seems clear that those cities which 
have failed to keep record of the number of cases found, 
and what was done in the way of getting them cured, stand 



*See the new, rewritten edition of "Medical Inspection of Schools" 
by Gulick and Ayres of the Russell Sage Foundation, Chapter IX; also 
Wallin's study of Oral Orthogenics in the Cleveland schools in Dental 
Cosmos for April and May, 1912. 



AILMENTS OF SCHOOL CHILDREN 143 

in efficiency far below cities which make such efforts. Prac- 
tically the only cities emphasizing the reporting of cure and 
treatment are Newark and the nursing division of Boston. 

Some of the chief weaknesses in the reporting of this 
defect seem to be as follows: 

a. Many cases are undoubtedly not "cases" at all, but 
fillers for statistical columns, "to frighten citizens into pro- 
viding a sufficient corps of doctors and nurses." The phy- 
sician at Summit makes a good distinction between cases that 
are slight and those that are really serious and demand im- 
mediate attention, as shown for three defects as follows: 

No. Cases No. Cases Percentage 

Found. Referred to M.D. Referred. 

Adenoids 34 34 100 

Enlarged Tonsils 116 39 25 

Defective Teeth 552 155 28 

Defective Vision 194 85 43 

Here it is evident that only such cases of adenoids as 
were really serious were recorded and all were reported. 
Why minor cases were not recorded as is the case of the 
other three defects named is not told. 

If such distinctions are made in all cases, the placing of 
minor, unreferrable cases on the individual record cards may 
prove of some slight value; but as a general principle of 
reporting in this field, experience in a number of cities seems 
to show that only such cases as need treatment and cure, 
that are really serious and demand attention by parents and 
family physicians, should be recorded and reported. This 
would reduce the Summit cases to those of the second 
column, and this proportion of reduction would probably 
apply to each city. 

b. Many of these cases are "re-inspections," instead of 
new cases. At the time of some inspection of the child, or 
at the time of the physical examination in the few cities that 
have examinations, a pupil is found, for example, with ade- 
noids. This is one new case. But the pupil does not obtain 
treatment, say, and is referred to the school doctor again, 
one or more times. These re-inspections, or better, "old- 



144 SCHOOL HEALTH ADMINISTRATION 

cases," are frequently counted as if they were each a differ- 
ent child with this defect, otherwise, on the poor report 
forms supplied, the physician would get no credit for his 
work. 

Good reporting must show the number of children with 
the defect as "new cases"; and all inspections to see if a 
child has procured treatment, is keeping up treatment, or 
is progressing well after an operation or other form of 
treatment must be recorded and reported as "old cases" 
inspected. See forms in last chapter, 

c. Negative cases are not deducted from the total num- 
ber of suspected cases. For example, a child is diagnosed as 
having adenoids. No careful manual examination is made 
or the adenoids are not very large or perhaps only tem- 
porarily congested. The physician cannot say for sure that 
this is a case for medical or operative treatment, but reports 
it for the family physician to pass upon. The family phy- 
sician examines the child and calls it negative, or no case. 
Unless a very skilled specialist in nose and throat ailments 
is the school physician, as is very seldom the case, later 
reports should deduct this case from the total. I know of 
no city that does this, although the Montclair reports make 
it a possibility. 

d. The nurses do not show how many cases have been 
referred to them by the school doctors and how many they 
have themselves found. Thus in Boston, for example, 
where the physicians are under the Board of Health and the 
nurses are not, we do not know how many of the 2,472 cases 
reported by nurses have already been found by the phy- 
sicians and referred to them, so we cannot tell how many 
cases were found in the city, or how many pupils suffered 
from adenoids. We suspect that the number is far less than 
the sum of the doctors' and the nurses' cases. 

In the case of Brockton, we know how many cases were 
found by the nurse, since the doctors are used only for con- 
sultation and consequently have no cases to report, all being 
found by the nurse. The nurse, however, fails to state 
the number of children who had adenoids, although we sus- 



AILMENTS OF SCHOOL CHILDREN 145 

pect from the report that it Is almost as large as the number 
of "cases." 

Reports must distinguish cases merely handed on by the 
physician from those found by the nurse, and must distin- 
guish between pupils and cases, or re-inspections. 

e. Treatments are frequently not recorded; many re- 
corded on the teachers' or pupils' statement without an in- 
spection by nurse or physician are really not treatments at 
all. A pupil reports treatment when he hasn't had one, to 
avoid trouble. Furthermore, a distinction should be made 
in the kinds of treatment obtained, operative or medical. 
A spray or gargle which has no beneficial effect is often used 
and is called a "cure" when adenoids are still there after its 
use as bad as ever. 

Reports should show that a real cure or improvement 
has or has not been effected. Only an inspection will estab- 
lish this. 

f. Another troublesome matter, influencing reports, is 
the fact that adenoids "come back." The famous English 
Board of Education (London) reports by Sir Geo. New- 
man, M. D., consider this. The 191 1 report shows (page 
50) that many children may be operated on three or more 
times and the bad symptoms still remain. Even after an 
operation which may well be called a treatment a child 
should not be called cured unless the bad symptoms : mouth- 
breathing, snoring respiration, nasal deformities, etc., cease. 
In the case of adenoids, this result frequently cannot be 
obtained without widening the child's nasal passages at the 
time and after the operation, and without breathing exer- 
cises directed by the regular or physical training teacher. 
The latter has been tried and found valuable in Montclair, 
N. J., by the physical training teachers. 

After all these strictures what have we? How many 
pupils In these cities suffered from actual, severe cases of 
adenoids or other nasal obstruction which needed real treat- 
ment, medical or operative; how many got such treatment; 
and how many were cured of their ailment or were only 
Improved? No one In the world can answer with accuracy, 



146 SCHOOL HEALTH ADMINISTRATION 

and hardly approximately. We must remember, too, that 
many severe cases missed attention in a number of cities 
because the children were not examined and because not all 
were even inspected for this defect. 

The daily work of doctors and nurses cannot now be 
reviewed; and the number of mere estimates necessary to 
a complete summary for the twenty-five cities is probably so 
great that the results will not carry conviction. The inspec- 
tion in most cities has necessarily covered only part of the 
elementary school population, so the figures would be much 
reduced by the various considerations given above, and 
would be raised if we were making the estimates for the 
number of ailments in the entire elementary school popula- 
tion. Tentative, empirical estimates seem to indicate that 
the number of cases set down as the sum totals for doctors 
and nurses is not far from the number of new cases, or 
pupils affected, to be found by both officials in the total 
elementary school population of 413,393 pupils, counting 
all as new cases found by the doctors and all as new cases 
found by the nurses and not referred to them by the doctors. 
This would make the number of children having serious 
cases of adenoids and nasal obstructions about five per cent 
of the number of elementary school pupils. The figures 
are only two per cent for Summit, the same in Winchester, 
and 12 per cent in West Orange; but of the last 195 only 
6^ were considered serious enough to refer to the parents 
and family physicians for possible treatment, making only 
about four per cent. 

Wherever we get the actual number of these cases that 
are really serious enough to be referred for treatment the 
percentage does not rise above that for the total of nurses' 
and doctors' cases for the twenty-five cities, five per cent. 
This is about half the number, or percentage, usually given 
as the number of cases. About ten per cent of all children 
examined are usually reported as having adenoids or other 
nasal obstruction.* In Milwaukee for the same year, 



*See 1913 edition of "Medical Inspection of Schools," by Gulick 
and Ayres, page 40. 



AILMENTS OF SCHOOL CHILDREN 147 

1910-1911, 19,616 pupils were examined, of whom only 
2,493 were recommended for treatment; the total number 
of physical defects found were 18,299, of which 11,380 
(over half) were defective teeth, and 1,049 adenoids and 
nasal obstruction. If no cases were counted both adenoids 
and "defective nasal breathing," and if all pupils with these 
ailments were referred for treatment, which seems very 
unlikely from the above figures, the percentage of cases of 
this defect is only about five. It is Interesting to note here 
also that there were on the average 6.2 defects for each 
child. 

2. ANEMIA 

For summary purposes this ailment may as well have 
been placed with malnutrition and debility, perhaps. It is 
given separate record because of the large number of sep- 
arate records given it In the reports. The sum of cases 
found by doctors and nurses Is 4,539, or less than one per 
cent of the total number of elementary children in the cities. 
Boston has a combined number of 2,832 or over two per 
cent of the school population but here quite evidently all 
the doctors' cases were passed on to the nurses who counted 
them again, and found 1,128 new cases themselves, unless 
some of the latter were duplications, from meeting an 
anemic child more than once. The number counted cured 
of this ailment was so small that the figures given were not 
put down. 

In the cities where there were open-air schools (S. Man- 
chester, Montclair, Schenectady, Cambridge, Providence, 
and Newark) It is Important and surprising to notice that 
this ailment Is one most frequently given as the cause of 
admittance, not tuberculosis. The children are anemic and 
run down, probably suffering from malnutrition, and need 
rest, food, and recuperation. The number of tubercular 
children of whom we hear so much are conspicuous by their 
absence from these reports (columns 167 to 172 of the 
table) only 81 cases being found by doctors that are not 
marked merely suspects, and only 223 suspected and actual 



148 SCHOOL HEALTH ADMINISTRATION 

cases together. The number of cases Is not great enough 
to cause alarm; the important thing is to find those pupils 
who will most surely become consumptives in early adult 
life, and give them special health education, diet, outdoor 
life, and treatment. 

Probably one per cent of the pupils are anemic. 

3. DEAFNESS, HEARING DEFECTS 

For this ailment, too, the returns are very variable. In 
Massachusetts and Connecticut the hearing and vision of 
pupils are tested by the teachers. There are no very definite 
standards of examination followed in this work; and the 
great number of teachers and other persons engaged in It, 
all with little or no supervision, makes for little accuracy 
In results. Where the tests are made by teachers, we fre- 
quently found that the teachers had got around the law 
of 1906 by detailing one of their number in each building, 
or a teacher on each floor, to make all the tests. A substitute 
is called into the teacher's room who does this work for 
herself and the other teachers, and thus a certain amount 
of school interruption is dispensed with, and a degree of 
uniformity is reached. In several cities many of the prin- 
cipals make the tests. This feature and the fact that in 
other places the nurses make these tests for the entire school 
system without any need of a substitute and with a great deal 
better opportunity for skilled work and uniform standards, 
have furnished the suggestion for the tentative standard 
plan found in the last chapter that only nurses should do 
this work in all cities. The reports of specialists in these 
fields to the legislature of Massachusetts before the law was 
passed, to the effect that teachers could make such tests even 
better than regular medical practitioners, would be even 
stronger when said of the nurses.* It would be distinctly 
uneconomical to employ relatively high salaried physicians 
to do any work that can just as well be done by nurses who, 



*See 1913 edition of "Medical Inspection of Schools," pages 179 
and 44 to 53, by Gulick and Ayres. 



AILMENTS OF SCHOOL CHILDREN 149 

hour for hour, receive only about one-third to one-half as 
much remuneration. 

The tests are chiefly the stop-watch and whisper tests, 
and common-sense is about the only standard. Children in 
outdoor life and in the school room should at normal dis- 
tances be able to hear easily distinct speech lowly spoken; 
consequently whisper or low-spoken sentences will probably 
always be an important part of good testing. The Massa- 
chusetts tests as given in detail in the book just mentioned 
are the models which most of the other cities follow. Treat- 
ment is rarely recorded, largely because the defect is often 
permanent, and is generally treated, if treated at all, indi- 
rectly by treatment or removal of adenoids, defective teeth, 
enlarged tonsils, chronic catarrh, colds, discharging ear 
(otitis media), and the like. 

The teacher's treatment of the child should, of course, 
be modified by reports of defective hearing; but the writer 
has found that this matter has been much neglected for 
frequently, and this is true of all ailments of school chil- 
dren, not enough attention has been given to notifying the 
teachers of the ailments and making it necessary and pos- 
sible for them to readjust themselves to the children in the 
light of this new knowledge of them. Some cities send a 
record of every ailment immediately to the teachers of 
the individual children, and some, like New Bedford, Mass., 
have small room-filing-cases on each teacher's desk for this 
purpose. It seems a good plan for the child to take such 
a room card with him to the nurse or physician for each 
examination or inspection, carrying it in a fold of clean, 
blank paper for its protection, and having the physician or 
nurse record their findings on the card and write any special 
report for the teacher on the clean slip of paper. The 
records of nurse and physician could be distinguished by the 
nurse using, say, red ink in her fountain pen and the doctor, 
black. I know of no city following this plan; but it is 
these details which help most to bring about efficiency. 

The percentage of defective hearing cases to total ele- 
mentary or entire school population can hardly be made, for 



I50 SCHOOL HEALTH ADMINISTRATION 

reasons given in connection with adenoids. In Summit, 
there were 12 cases among 1,034 elementary school children, 
reported as follows : 

"Ears — The number of pupils with defective hearing or 
discharging ears was twelve (about i per cent). This is 
about one-half the number found last year, and is due 
largely to the correction of defects by medical treatment, 
or removal of adenoids and enlarged tonsils since the last 
examination was made." 

How many cases had defective hearing only, we are 
not told. If there were eight serious cases, that were riot 
merely temporarily defective because of bad colds, which 
is probably a big estimate, the percentage would be .7 of 
one per cent. 

This caution is true for practically all nose, throat and 
ear ailments, the proportion of cases found being greater 
in the winter months when the children have bad colds. A 
room inspection of children in September will give a certain 
number of cases of adenoids, tonsils, defective hearing, dis- 
charging ear, and the like; and if the same children are 
again inspected in December or February a great many more 
cases will be found. Physicians and nurses who are most 
conscientious and intelligent in this work take care to distin- 
guish between temporary and severe or chronic ailments. 

The percentages for some of the cities are as follows 
(for elementary children only) : Norwood, .9; Winchester, 
i; West Orange, .3; Montclair, (16 cases), .5; Meriden, 
.4; Brockton, 1.8; Hoboken, .7; Trenton, .5; Newark, .6: 
in all an average of about .7. As these are cities where the 
tests were made for most of the elementary school children, 
we can see that the actual percentage is well under one per 
cent. Taking the figures as they stand, the percentage for 
New Bedford (414 cases) is over 3; for Rochester (628 
cases), 2.6. These need not be taken seriously. The nurse 
at New Bedford for the year was new to the work, and had 
not a developed standard and the cases were first found by 
the teachers; while the work at Rochester was done by 
school physicians who evidently set the standard too low. 



AILMENTS OF SCHOOL CHILDREN 151 

Although most investigations of this defect place it at one 
per cent of the children examined in the elementary school, 
the writer is convinced that half that amount, .5, would be a 
truer statement of the actual number of cases where the 
defect was a genuine handicap to the children; and that it 
would be better, as said, to report only these, and make 
adequate provisions for their special consideration and 
treatment. 

4. DENTAL, OR TEETH DEFECTS 

The reason for using the term "dental" instead of 
"teeth" is the same as that for using the words "eyesight," 
"enlarged" before tonsils, and "glands" before enlarged: 
for various administrative and other reasons these terms 
must be emphasized by position. Some of the most im- 
portant school ailments can be given a forward place in the 
classification in this way, and physicians and nurses can 
easily learn to use this form of nomenclature when it be- 
comes standard. An alphabetical order makes some terms, 
otherwise not so desirable, good for this purpose. 

Defects of the teeth which require dental treatment 
and advice are among the most important of the ailments 
of childhood, both because of their frequency and because 
of their indirect effect on general health. Defective teeth 
might with truth be called "the great American disease" as 
the figures in these columns show. In any general sum- 
mary of the ailments of childhood and youth, such as shown 
in the next table, defective teeth will probably always stand 
at the top of the list in the number of children affected. 
The figures given in these columns (58, 59, 60) represent 
for the most part the number of children affected, not the 
number of teeth decayed, or needing dental care. This is 
especially true of the doctors' cases. One case of defective 
teeth may give the nurse several inspections for toothache, 
"gum-boils," etc.; but on the whole each child with defec- 
tive teeth has been counted but once. 

The chief administrative and statistical problems to be 
considered in this rapid review of the table are : 

a. Ratio of number of children with defective teeth to 



152 SCHOOL HEALTH ADMINISTRATION 

number of elementary school children, and number of 
pupils examined. 

b. Percentage of children with teeth seriously defective. 

c. Relative attention to teeth by Boards of Health and 
Boards of Education. 

d. Percentage of cases treated. 

e. Effect of treatment upon school progress. 
All, of course, cannot now be answered. 

The following quotation from the report of the medical 
examiner. Dr. W. J. Lamson, of Summit, In his June 30 
report, 191 1, will serve as an illuminating preface to the 
examination of these teeth columns : 

"Teeth — Particular attention has been paid to the teeth, 
as their condition is of so much Importance to the young 
child. It is deplorable to find that over 50 per cent of the 
school children have an unsound condition of the oral cavity 
— either decayed or unclean teeth. A pupil, for instance, 
with decayed teeth, Is constantly absorbing poisons Into the 
system. The glands of the neck try to protect the rest of 
the body, become enlarged, and frequently later become 
tubercular. The child Is anemic, listless and unhealthy. 
Parents neglect to have such teeth filled or extracted, because 
the child is young. And yet It is of great Importance to 
the child to have clean and sound teeth. One hundred and 
fifty-five cases were urgently in need of dental care, and 
their parents were notified. Each pupil was told the Im- 
portance of oral hygiene and urged to use a tooth brush 
dally." 

The nurse In her report, which largely omits statistics 
and gives only the personal side of the equation, also em- 
phasizes the Importance of caring for defective teeth because 
of their bad effect upon digestion, and strongly urges a 
dental clinic. 

Here we find 552 children with defective teeth, as de- 
scribed, among 1,034 pupils examined, or 53 per cent. But 
only 155 cases were "urgently In need of dental care" and 
referred to parents for dentistry. This number Is only 15 
per cent of the total number of children examined, and but 



AILMENTS OF SCHOOL CHILDREN 153 

28 per cent of the number of children with defective teeth. 

The ratio of defective teeth to elementary school en- 
rollment Is 552 to 1,088, or about 51 per cent. For seri- 
ously defective teeth It Is only 14 per cent. 

How many temporary teeth are here recorded; why 
unref erred cases were recorded; why parents of all children 
with teeth defective enough to record were not Informed; 
how many of the 155 received treatment that could be 
called cures, we are not told. 

One other fact, only, Is given: that "In school No. i 
where the higher grades (seventh and eighth) are located, 
27 per cent of the scholars had defective teeth, as compared 
with 62) per cent for the rest of the schools." 

This fact Is true for all cities, that all ailments decrease 
with the age of the pupils from about the third or fourth 
school years, except defective vision. In Summit, the 
ratios of defects In the higher grades and In the lower grades 
were as follows: Adenoids, i per cent and 4 per cent; en- 
larged glands, 6.5 per cent and 11 per cent; defective 
vision, 21 per cent and 18 per cent; enlarged tonsils, 9 per 
cent and 12 per cent; vermin, 3 per cent and nearly 17 per 
cent (16.6). What Ayres, In his book on "Laggards In 
Our Schools," has shown to be true for his New York cases, 
Is found true wherever studied. Most or all of childhood's 
ailments decrease with age except defective vision, which 
increases. Not a very great tribute to the hygiene of the 
schools rooms and teachers of America ! For myopia Is a 
school ailment. 

DEFECTIVE TEETH IN SOUTH MANCHESTER 

Here a "special physical examination was made of all 
pupils in the school system" In October, 19 10. Of 1,725 
pupils examined, 538 were reported as having defective 
teeth, a percentage of 31. We should expect a smaller 
percentage where high school pupils are Included in the 
examination. 

OTHER CITIES 
Counting the number given by the nurse for Norwood 



154 SCHOOL HEALTH ADMINISTRATION 

(984) we have a percentage of 62, or almost two-thirds of 
the elementary school population, according to the stand- 
ards of the nurse and doctor. Here record was kept of 
112 children who received dental treatment, about 11 per 
cent of those reported as needing it. 

In Winchester, an excellent system of co-operation with 
the dental association has been worked out, but the nurse's 
report does not show it for the year put into this study. 
717 children were examined by dentists with the aid of the 
nurse; and 84 of these were taken to the clinic and were 
treated at the small charge of 25 cents each. The 1910-11 
report is better in this respect. The school dentists exam- 
ined the teeth of 2,153 children and 1,665 cases were found 
defective, or about 77 per cent of the children. To the 
parents of 1,544 of these 1,665 children dental notices 
were sent, about 71 per cent of the number examined. The 
number who received treatment is not given, although 83 
children received reduced rates at the clinic, or a little over 
5 per cent of the referred cases (1,544). Little can be 
told from these facts. It is probable that dentists count 
too many very minor cases. The 19 12 report states that 
in previous years "from 90 to 95 per cent of the pupils 
examined were reported as needing dental attention," 

West Orange and Montclair quite evidently overlooked 
teeth almost entirely. Meriden physicians and dentists 
found 1,648 children with defective teeth among 3,621 
pupils examined. Of these, 167 cases, or 10 per cent, 
obtained treatment (7 primary teeth and 160 permanent). 
Here we have (where "only the most obvious cases were 
noted," according to Superintendent Kelly, 1910-11 Report, 
page 33), 45 per cent of the pupils examined with defec- 
tive teeth. The report goes on, "But more startling still 
is the indifference of many parents and their sympathizers." 
He urges dental clinics which would be patronized very 
generally, he thinks, A part of this indifference is due to 
the fact that the work was so new at this time, really get- 
ting started little earlier than the second month of the 
school year. 



AILMENTS OF SCHOOL CHILDREN 155 

Some of the other percentages are as follows: 

Newton, 2207 cases, on elementary school population, 5,987 — 37 per cent 
Yonkers, 3063 cases, on elementary school population, 12,562 — 24 per cent 

There were very probably many more cases than this 
latter number, because two physicians could not cover well 
the entire city. Part of the nurse's cases may be new 
cases not found by the physicians. Of these cases 1,235 
cases are reported as cured, or about 40 per cent. The 
author's own careful summary of the reports of the phy- 
sicians, however, showed only 1,631 cases of defective 
teeth; and only 12 cases of defective teeth were found 
in the nurse's reports; and yet the printed summary made 
by the nurse shows 2,474 cases and 662 treated. There 
Is nothing in the monthly reports to back up these figures. 

In Trenton, with a very much larger elementary school 
population, and 8 physicians working five days a week each 
Instead of two, as at Yonkers * — in Trenton, with 713 
school visits, or an average of 89 each, the number of cases 
of defective teeth found is only 3,276, or 31 per cent of 
the 10,587 children examined. Here the principals also 
report results, although some neglected it. Of 2,289 cases 
reported by them, only 633 (less than 6 per cent of the 
number examined) are recorded as being referred for treat- 
ment, or only 28 per cent. Of these only 13 are reported 
as cured, 76 improved and 292 not treated. These figures 
simply show that the work of seeing what was accom- 
plished was not done, and emphasizes the experience bought 
dearly in New York and elsewhere that no cures, treat- 
ments, improvements, or anything of the kind should be 
reported without an inspection by the physician or nurse 
to ascertain that fact. 

Notice of the excellent dental clinic in the City Hall at 
Trenton will be made in a later chapter. 



*Where only 71 school visits were made by the two doctors in the 
year, about 35 each, 6 schools visited but once, 4 schools but twice, 3 
but thrice, 2 four times, i five times, and i seven, i eight, i nine and 
I eleven times, not one of the 20 schools being visited by the physicians 
more than 1 1 times, and the average less than four visits each. 



156 SCHOOL HEALTH ADMINISTRATION 

In W aterhury the Dental Association made a careful 
investigation of the condition of the children's teeth and 
have worked out probably the best statistical reports of 
teeth defects found in any of the cities. This report may 
be found in the 1910-11 report of the superintendent of 
schools and In later reports, and a complete summary for 
seven schools Is here appended. In the annual report a 
separate report on the same form is given for each school. 
"The only cost to the Board of Education has been the 
furnishing of a dental chair and some other necessary ap- 
paratus, the whole expense amounting to less than two 
hundred and fifty dollars ($250)." 

SUMMARY OF DENTAL EXAMINATION OF SCHOOL 
CHILDREN IN SEVEN SCHOOLS BY THE WATERBURY 
DENTAL ASSOCIATION IN 1910. 
Grades. 23456789 Totals. 

Condition of the 
mouth — 

Good 256 389 279 351 236 233 137 126 2,007 54% 

Bad 215 352 440 265 218 III 76 58 1,735 46% 

Condition of the 
gums — 

Good 392 583 545 445 324 278 178 150 2,905 77% 

Bad 83 178 172 160 129 64 33 34 583 23% 

Use of the tooth 
brush — 

Yes loi 238 239 255 240 191 130 152 1,646 44% 

No 362 522 361 357 221 152 83 42 2,100 56% 

Teeth filled— 

Yes 58 64 93 92 100 74 57 51 589 16% 

No 426 694 601 523 345 267 158 131 3,145 84% 

Mal-occlusion — 

Yes 154 404 324 329 201 170 102 95 1,679 45% 

No 327 456 373 286 251 173 105 87 2,058 55% 

No. of teeth 

decayed .. .2,721 4,583 3,631 3,105 2,008 1,699 i,i75 993 19,912 or 

5.3 each 
Total No. 
pupils 474 758 693 618 455 342 214 182 3,736 

Here, then, we have a table made by dentists them- 
selves, and from it we can make the following more or less 
pertinent observations : 



AILMENTS OF SCHOOL CHILDREN 157 

a. The number of children with bad dental conditions 
Is astonishingly large. Among 3,736 children in all grades 
from the second to the ninth, inclusive, there were found 
19,912 decayed teeth, an average of about 5 1/3 to each 
child. Unfortunately, we are not told how many children 
had defective teeth among the 3,736. The horizontal col- 
umn marked "condition of the mouth bad" does not repre- 
sent this number. Here we see that 1,735 children, or 46 
per cent of those examined, had a bad condition of the 
gums or mal-occlusion, but some were counted good who 
had decayed teeth. 

b. The figures are not accurate. The dentists evidently 
tried to place all the children In one of two classes for the 
first five items. If they had done so the sum of the two 
numbers for each item would be the number of children 
for the grade, given at the bottom. However, there Is a 
fair degree of correspondence, the difference usually being 
slight. 

c. The number of cases of defects Is greatest In the 
third grade, with a few less in the second grade, almost as 
many or more in the fourth grade, and a gradual decrease 
to the ninth. 

For bad condition of the mouth we have the following 
percentages of children defective : 

Grades. 23456789 Totals. 
No. pupils 

examined ...474 758 693 618 455 342 214 182 3,736 

No. defective.. .215 352 440 265 218 in 76 58 i,735 
Per cent. 

defective ... 45 46 63 43 48 32 35 31 46 

Counting all children who have decayed teeth or other 
bad condition of the oral cavity, we may conclude that 
probably not far from 66 per cent of our elementary school 
children are so affected, especially in the first years of med- 
ical Inspection. 

5. ENLARGED TONSILS 

This ailment is quite closely associated with adenoids. 
We should expect to find more cases of it than of adenoids, 



158 SCHOOL HEALTH ADMINISTRATION 

because, as the superintendent at South Manchester puts 
it, "when the examiner found a well defined case of en- 
larged tonsils he did not take the time to make an accurate 
diagnosis for adenoids, for it is the custom of all surgeons 
who operate for tonsils to remove all adenoid tissue" (1911 
Report, page 20). Enlarged tonsils are easily seen, while 
adenoids very rarely can be seen.* This fact should help 
to make our findings for enlarged tonsils more satisfactory 
than those for adenoids. 

Let us turn our attention first, again to the actual and 
proportionate numbers of this ailment among the children 
here represented. In Summit, "there were 116 cases. 
Of these only 39 were so much enlarged as to 
form a serious obstruction to breathing, and the pupils 
advised to have them removed. This was done in many 
cases." (Report, page 22.) Here is a percentage of the 
number examined (1,034) of 11.2 for all cases and 3.7 
for the serious ones. No mention is made by either doctor 
or nurse of following-up pupils and parents to see that, or 
if, they procured treatment. 

In South Manchester, of 1,725 pupils examined in ele- 
mentary and high schools, 276 children had enlarged ton- 
sils, or 16 per cent; 27 of the 276, or 9.7 per cent, had 
had operations before the report in June. 

In Winchester, with an elementary school enrollment 
of 1,505 pupils, after several years of thorough inspection, 
138 cases were found, or 8.5 per cent; and 62 of the cases, 
or 45 per cent, had operative treatment. 

In Montclair, among 3,255 elementary children only 
60 cases, less than 2 per cent, were found, but of these 37, 
or 61 per cent, had operations. 

Some of the other figures, where known, are as follows : 



*Dr. Relic's helpful little book on "Safeguarding the Special Senses," 
F. A. Davis Co., Philadelphia, gives an excellent illustration of visible 
adenoids and tonsils, page 108. 



AILMENTS OF SCHOOL CHILDREN 159 



ENLARGED TONSILS 



Summit Exams.. 



No. 
Elementary 

School 
Children In- 
spected or 
Examined. 

1,034 



Prob- 
able 
Num- 
ber of 
Cases. 



Num- 
Per- ber of 
cent- Opera- 
age De- tions Re- 
fective. ported. 



Percent- 
age of 

Ailments 

Given 
Operative 

Treat- 
ment. 



116(39)33-6% 11.2 
Referred 



S.Manchester .... 1,725 

Winchester 1,505 

Montclair 3,255 

Brockton 7,589 

Waterbury 12,077 

Yonkers 12,562 

N. Bedford ii,739 

Trenton Exams... 10,587 

Cambridge 15,445 

Lowell 11,438 

Rochester Exams. . 15,157 

Providence 5, 601 

New^ark Exams... 24,310 

Boston 61,055 



276 

138 

60 

1,633 
130 

1,235 
713 
1,723 (510)30% 
Referred 

300 

721 
4,452 

272 
4,588 
4,101 



16 

8.5 

2 
21% 

I 

9.8 

6 
16.4 



27 
62 

37 
125 
"Many." 
195 

31 

50 



9-7 
45 
61 

7-7 

15 
4-3 
2.9 



2 "366 home visits" 

6.3 175 24 

29 Not separately given 

4.9 207 75 

18.8 416 9 

6.7 913 22.2 



159.6 2,238 


275.8 


10.6 


25. 


average 


average 


10.7 9,808 


28. 



195,079 20,458 

N. Y. City (1911). 230,243 34,639 

RESULTS 
What conclusions can we draw from these variant facts? 
The average percentage of cases of enlarged tonsils, as 
compared with the number of children examined, inspected, 
or the entire elementary school enrollment, as the case may 
be, is 10.6 per cent, while the average percentage of these 
cases given operative treatment is 25. In Summit, where 
we are given the facts, only 39 referable cases were found 
among the 1,034 children examined, or 3.7 per cent, al- 
though the number of recorded or minor cases is 11.2 per 
cent. In Trenton, only 510 referable or serious cases were 
found among 10,587 children examined, or 4.7 per cent, 
although the total number of cases recorded makes a per- 



i6o SCHOOL HEALTH ADMINISTRATION 

centage of 16.4. These figures alone would lead us to 
suspect that the number of real, or serious, cases would 
not for all cities give a percentage as high as 10.6. From 
this and personal observation, I should say that each of the 
five figures above 15 per cent could be divided by two and 
a more accurate statement of the number of cases of 
enlarged tonsils obtained. One reason for this is that the 
examination covered only a part of the school population, 
while children were inspected from all parts. Likewise, it 
is believed, but cannot be demonstrated, that in those cities 
with percentages of cases less than 6, physical examinations, 
or even careful inspection for the purpose, would increase 
the figures up to six or more. These changes would make 
an average of a little over eight per cent. Half or two- 
thirds this sum would be near the number of serious, refer- 
able cases, perhaps. 

As a general estimate and conclusion, we judge that 
not far from eight per cent of elementary school children 
have enlarged tonsils, and that about five or six per cent 
have serious referable cases which should probably have 
operative treatment. Probably half to two-thirds of these 
children would need to be operated on for adenoids at the 
same time. 

Whether cities that have had medical "inspection" for 
some time are freer from this ailment than others not hav- 
ing had it, cannot be told from these figures. The average 
for the newer systems is below that for the old. Meriden 
and Jersey City, practically started in this year, have given 
few or no facts. Whether the older cities had found fewer 
cases each year is also difficult to determine. Ideals and 
standards for the work change. Generally, when a system 
is beginning, every slight deviation from the normal, if 
nothing more than a bad cold and a slight swelling of ade- 
noids and tonsils due to it, is recorded, and children are 
excluded in great numbers for relatively trifling reasons. 
Gradually, the physicians and nurses see that they will get 
better results if they pick out only the serious and urgent 
cases; keep children in school as much as possible, even 



AILMENTS OF SCHOOL CHILDREN i6i 

cases of pediculosis (nits) under treatment; and then make 
a good effort to get these important cases treated and cured. 
This seems to be the road toward maximum efficiency. 

As to the Board of Health versus the Board of Edu- 
cation problem, we notice that the only cities giving no 
attention to this serious ailment of childhood are boards 
of health (Mt. Vernon, Newton and New Haven) with 
the exception of Jersey City. No board of health has what 
might be called physical examinations with individual health 
record cards, except Rochester. The only board of educa- 
tion city among three or four that have almost insignificant 
numbers of cases found Is Montclalr. With the exception 
of Rochester it can be said, In general, that even if they 
(the board of health systems) are much older on the aver- 
age than board of education systems they are very much 
less efficient in this respect. 

The proportion of school population seriously affected 
in one year is about 6 per cent. 

6. DEFECTIVE VISION 

Defective vision Is very largely a school ailment. And 
here again the work is almost inextricably intertwined with 
other departments. In Massachusetts, Connecticut and to 
a large extent in New York, vision tests are conducted by 
teachers and principals. In several places the nurse does 
the testing, in others the physician, while in others the 
physical training teachers help. This shows again the need 
of one integrated Department of Hygiene In a school system 
under one director where we now have the following scat- 
tered and uncorrelated agents: doctors, nurses, physical 
training teachers, playground Instructors, open-air school 
teachers, dentists, sanitary inspectors, etc. Perhaps in many 
cities, as at Summit and Brockton, the nurses can be made 
also truant officers. Why not do this work while very prob- 
ably at or passing the home on regular nursing visits? 

No very definite and fixed standards for testing the 
vision were found. There are so many persons doing the 
work, even where each principal of a school tests all his 



1 62 SCHOOL HEALTH ADMINISTRATION 

own pupils, that the results must be taken with reservations, 
and comparisons made only with great care. The Snellen 
test charts are the ones principally used. Some call all 
vision less than 20/20 defective; others, less than 20/30; 
and all use their judgment in referring cases showing signs 
of eye-strain, even though 20/20 may be easily read. The 
Massachusetts directions for testing, as given in "Medical 
Inspection of Schools," by Guhck and Ayres (1913 edi- 
tion), page 45, are also commonly followed. The great 
number of such cases declared negative, or not needing 
glasses, after examination by oculists throw doubt, however, 
on the 20/20 or 20/30 standards. It is normal for there 
to be some variation in the vision of children; indeed varia- 
tion is the most characteristic thing about children. This 
whole problem needs investigation under competent super- 
vision. Perhaps 20/30 or less, as used in Newark, would 
be a better division line. We recommend 20/40, unless 
there are other serious symptoms of eye-strain. 

The Providence Board of Health has a school oculist 
who gives a very detailed report of his findings, but not 
of his methods, in the 19 10 report. He devotes two morn- 
ings a week to the examination of children referred to him 
by the school doctors. His salary is $500 a year. Free 
prescriptions for glasses are given all needy children. We 
need free prescriptions by the best school oculists for all 
school children. 

In Summit we find the following report by the phy- 
sician: "Eyes. — While the total number of cases with defec- 
tive vision and various other diseases of the eyes is rather 
in excess of last year (194 and 185), yet more than one- 
third of this number is made up of last year's cases, which 
are almost all being treated by properly fitted glasses. It 
is gratifying to note that when attention is called to the 
need of correction of defective vision, the parents as a 
rule attend to the matter promptly. Two cases of severe, 
chronic trachoma (granulated lids) were operated on, with 
complete cure. One pupil, 16 years old, had such bad 
eyesight that he could only see letters at fifteen feet distance 



AILMENTS OF SCHOOL CHILDREN 163 

which he should have been able to see at eighty feet. There 
was a constant eye-strain and twitching of the lids, which 
was completely cured by proper glasses, and his vision, by 
their means, is now normal. Some pupils, by wearing 
glasses for a time, have had their vision so much improved 
that glasses are no longer necessary, and the accompanying 
eye-strain, school headaches, watery eyes, etc., have dis- 
appeared. In all, eighty-five new cases of defective vision 
were advised to consult an oculist." The nurse reports 
having "spent twenty-four afternoons at Dr. Vaughan's, 
the eye specialist's, with children whose eyes needed atten- 
tion." 

The facts for defective vision, as nearly as they could 
be obtained, are as follows: 

DEFECTIVE VISION 

Percentage 

No. Elem. Probable Number of num- 

children number Per- obtained ber of 

examined. of cases. centage. glasses. cases. 

Summit 1,034 194 19 (8) a h 

Norwood 1,571 El. Pup. 60 3.8 5 8.3 

Winchester 1,505 El. Pup. 220 15 70 29 

Montclair 3,255 El. Pup. 51 1.5 47 

Meriden 3,621 Bxam'd. . . . . 75 

Hoboken 8,773 Exam'd. 247(1457) 3 (17) 82 33 

Schenectady 10,121 El. Pup. 562(6568) 5.5(8) 21 3 

Yonkers 12,562 El. Pup. 676 5.4 212 31 

New Bedford 11,839 El. Pup. 637 5.4 

Trenton 10,587 Exam'd. 619 5.8 67 11 

Cambridge 15,445 EI. Pup. 194 1.2 14 7 

Providence 31,946 El. Pup. 685* 2 250? 86? 

Newark 24,310 Exam'd. 3003 12.4 989 32 

Boston 61,055 Insp'cd. 2000 3.3 ? 1742 ? 87 ? 

Sum 82.8 277.3 

Average 6.4 28 

a85 referred. &"Almost all." *491 prescribed glasses. ?Treatment. 

Here again records are such that scientific data are 
hardly obtainable, and generalization must proceed cau- 
tiously. On the stand that only referable cases should be 
reported. Summit would have a percentage of the number 
of elementary school children examined of about 8, instead 
of 19. The same would probably hold true of Winchester 
and of Newark. Very low figures below 4 are probably due 
to the fact that there were visual examinations made of only 
a part of the elementary school population, those referred 
by teachers, and those who were found by a partial routine 



1 64 SCHOOL HEALTH ADMINISTRATION 

examination. The percentages of cases found here are 
smaller than those usually given. 

From my observations, and from these data, I am 
convinced that most of the high percentages given in reports 
of medical inspection are unnecessarily alarming, since they 
really mean little when carefully analyzed. They are prac- 
tically always based upon the number of cases found by 
the standard used, and not by the number of cases referred 
for treatment, which is nearer the actual number of genuine 
cases. Many of the latter even are only "suspected" cases 
on which the parents are advised to obtain advice. More 
confidence must be placed in careful examinations, but even 
these vary considerably in the above list. Where physical 
examinations were made, as in the case of Newark, of only 
part of the elementary pupils, and cases referred for vision 
tests from among the non-examined children, we must lower 
the percentages. 

As a final judgment, I should say that the average given 
above is not very far from the actual percentage of ele- 
mentary school children with this defect, when the examina- 
tion has covered all grades. Perhaps not far from 7 per 
cent of elementary school children will be found to need 
glasses as a remedy for their defective vision. This would 
mean two or three children in each school room. The 
number will be found to increase with age. This estimate 
Is practically that made by eight ophthalmic surgeons who 
by special appointment examined 2,000 school children in 
London in 1904.* Their examinations demonstrated that 
about 7.3 per cent of all children in the elementary schools 
suffer from 20/60 or worse vision. The percentage near 
20/40 and less was 12.6. This last seems to be about the 
standard used at Newark, although in reality it is given 
as 20/30. 

The relative numbers of cases of various kinds are 
given in great detail in the 19 10 report of the Providence 



^Cornell, page 579. 



AILMENTS OF SCHOOL CHILDREN 165 

Board of Health, of which the following is a section with 
percentages computed: 



Vision 




Number of 


eyes 


Percentage 


20/15 




12? 




10 


20/20 




201 




16 


20/30 




243 




20 


20/40 




167 




14 


20/50 




95 




8 


20/70 




162 




14 


20/100 




159 




13 


20/200 




127 




10 


There were 


685 


cases which had been found by teachers, 



nurse and physicians; and for these the oculist prescribed 491 
pairs of glasses, or nearly 72 per cent. Ten eyes (not chil- 
dren) were found with a total loss of vision; and 28 children 
with supposed defective vision were found to be only 
illiterate. 

The question of whether vision testing should be done 
only by oculists has not been scientifically answered. Prac- 
tically, doctors, nurses, and teachers in the various cities 
simply find the cases which, according to rough estimates, 
should receive examination by an oculist. Until we have 
clinics which will furnish prescriptions and possibly glasses 
at public expense, as school books are now furnished, the 
present system will probably be best. Another alternative 
is to do as Providence has done In supplying accurate diag- 
nosis with prescriptions for glasses to all who desire it, and 
are recommended by the nurses, and glasses to those only 
who are unable to pay for them. 

The nurses have been very successful in many cities in 
helping needy children to obtain glasses. In practically 
every city there are numerous individuals and organizations 
that are glad of the chance to furnish glasses to the children 
of needy parents. In Lowell, Superintendent Whitcomb has 
for years furnished needy children with money for glasses 
out of his own pocket. Such sacrifice is needless, and stands 
in the way of acquainting the public with school problems 



1 66 SCHOOL HEALTH ADMINISTRATION 

and school needs. The numerous ways devised by superin- 
tendents and others in obtaining assistance along a great 
variety of health lines without school expenditure and with 
benefit to the public, as found in a number of the cities 
visited, almost leads to the conclusion that a superintendent 
can get almost anything he wants for the schools free of 
charge, if he knows how to mould public opinion and reach 
the people who desire to give services or money or both to 
some worthy cause, Denison's book on "Helping School 
Children" (Harper's) is full of illustrations of this prin- 
ciple, and points out an almost unworked field before us. 

BOARDS OF HEALTH VS. BOARDS OF EDUCATION 

What does the comparative treatment of defective vision 
in the schools show as to the relative efficiency of Boards 
of Education and Boards of Health? Of four cities giving 
no attention to this very important school ailment, three 
were board of health cities. In New Bedford, where the 
doctors but not the nurses are under the Board of Health, 
the former have practically neglected this ailment, finding 
only five cases to the nurse's 632. There is good excuse for 
this perhaps in that teachers are required by law to make 
such examinations in Massachusetts. This would practically 
excuse, also, the other boards of health in other cities, for 
this ailment. By far the best report on this subject is found 
in the report of the Board of Health of Providence, and 
the 191 1 report is still better.* 

In the cities given in the above table, however, where 
boards of health have attempted this work, we could com- 
pare the two forms of administration on the following bases 
for which we have data : 

a. Percentage of elementary school children examined 
for vision. 

b. The percentage of cases found. 



*In general, the reports on Medical Inspection by Dr. Charles V. 
Chapin, of this Board of Health, are in many ways quite superior to 
those of many or most other cities. 



AILMENTS OF SCHOOL CHILDREN 167 

c. The percentage of cases procuring glasses, or other 
treatment. 

The quality of the work done in examination cannot well 
be put in the form of a numerical coefficient, although we 
could say that the examinations of the oculist at Providence 
were undoubtedly better than those in other cities. The 
amount of work is shown to some extent by the number of 
cases found; for those cities reporting percentages less than 
three or four of the elementary school population, certainly 
did not reach all the children. Six cities fall below four 
per cent, 3 under the boards of health. But there are, in all, 
9 board of education cities to 6 board of health cities, and 
one of the latter, Boston, is partly administered by the Board 
of Education. This would give the advantages to the boards 
of education, the percentages falling below being about 33 
for the boards of education and 50 for the boards of health. 
Both Boston and New Bedford, especially the latter, are 
lifted up by the school nurses in the department of education. 
The three cities with high percentages are all board of 
education cities. These higher percentages, may not be 
virtues where discretion has not been used. In these three 
cases, however, I think they represent careful, painstaking 
work with a large percentage or all of the children. 

GLASSES 

Little can be judged from these figures. The average 
percentage of cases treated or cured by glasses for the ten 
cities reporting is 28. The average for the board of health 
cities is 11 per cent, while the average for the boards of 
education is 33. Boston is here counted as a board of edu- 
cation city for this function, since the nurses reported 1,581 
cases to the doctors' 617, and were the ones who got the 
treatments and recorded them. 

The following conclusion can probably be drawn legiti- 
mately from these facts: 

As a rule, these boards of health are less efficient than 
are these boards of education with respect to finding cases 



1 68 SCHOOL HEALTH ADMINISTRATION 

of defective vision, and especially in obtaining and reporting 
cures. 

Providence stands out as an exception. 

191 I REPORT OF THE PROVIDENCE OCULISTS 

This leads us to add some further facts from the last 
Providence report on this problem of finding and curing 
defective vision. 

Two oculists are now employed (19 11 Report) two 
afternoons a week for about two hours each afternoon at 
the Fourth Ward Room for examining eyes, at salaries of 
$500 each. All pupils who are found with defective vision 
in the schools by teachers or nurses may now go to these 
oculists for free examinations and prescriptions for glasses, 
or medical treatment. One oculist has reported for only a 
half year. Together, there were 646 cases, for whom were 
prescribed 496 pairs of glasses (77 per cent) and of whom 
the nurse saw 420 and obtained or reported 339 as "having 
treatment," which if we were to interpret as meaning glasses, 
would be 68 per cent of the number prescribed glasses, and 
81 per cent of the cases seen by the nurse. A small per- 
centage of the cases needed medical treatment. Two pos- 
sible fallacies lie here : There were probably many children 
with defective vision who did not go to these oculists, so the 
percentage of cases treated was probably much smaller, and, 
second, treatment may mean glasses in only a small per- 
centage of cases. 

This illustrates again the common failing to give the 
facts upon which estimates can be made, even in the best 
reports. (Our estimate of children needing glasses or an 
operative treatment is seven per cent.) 

7. STRABISMUS, CROSS-EYE, SQUINT 

This is a vision defect which is emphasized by separation 
from the others. Dr. Reik, in his "Safeguarding the Special 
Senses," expresses sound medical experience when he says, 
that "practically all cases of crossed eyes, even of many 
years standing, can be rectified, and when one considers what 



AILMENTS OF SCHOOL CHILDREN 169 

a difference in personal appearance it makes, the disagreeable 
effect of such an eye upon those who must come in contact 
with the afflicted person, and the simplicity of the operation, 
it looks like a sin against the community to allow such per- 
sons to retain their deformity" (page 46). The ailment is 
only the failure of the eyes properly to co-ordinate because 
of muscular or refractive errors, and the giving up of the 
struggle to use both eyes together. One only is used, and if 
the other is constantly neglected through habit or other cause 
it frequently goes blind. So this ailment, which is quite 
commonly neglected, should be given special attention in 
early school life, or before, whenever the nurse or teacher 
finds such a case among the little children in the homes. 

SomxC cities did not keep separate records of this ailment, 
and several did not record the ailment at all. There were 
two cases in Summit among 1,034 children. Waterbury had 
89 cases in an elementary school population of 12,077, a 
much larger percentage, but little less than one per cent (.7). 

Yonkers reports 47 cases found by the doctors.* Taking 
47, we have a percentage of the elementary school enroll- 
ment of .4. Taking the several cities, and using the nurses' 
figures for Cambridge and the physicians' in Boston as is 
reasonable, we have: 

Children. Cases. Percentage. 

Waterbury 12,077 89 .7 (7 in looo) 

Yonkers 12,562 47(25) .4 (.2) 

New Bedford 11,839 221 1.8 (iSiniooo) 

Trenton 12,774 26 .2 

Cambridge 15,445 95 -6 

Providence 31,946 loof .3 

Boston 95,970 173$ -2 

4.2 
Average .6, or 6 in a 1000. 
fOculist. ^Perhaps more. 

Leaving out New Bedford with its high figures, we have 
a percentage of .4, or four in one thousand elementary 

*Our summary of the doctor's reports shows only 25 cases; while 
the nurse reports 12 cases treated, while our summary of her reports 
shows only 6 cases. 



lyo SCHOOL HEALTH ADMINISTRATION 

school children. Nothing has yet been brought out to show 
whether the ailments of any kind vary much with place and 
length of time these medical inspection systems have been in 
operation. Our estimate is about seven cases in a thousand. 

Very few of these cases are reported as having had treat- 
ment, operations, or glasses. This is due only partly to ineffi- 
ciency. Physicians and nurses are frequently not sure that 
it is necessary or their province to follow-up thoroughly all 
cases to see that they do obtain the care they need. A later 
chapter will show that they do not get results amounting to 
very much without thorough follow-up work, and it is ap- 
parent that neither tests of efficiency nor adequate knowledge 
of health facts can be obtained without satisfactory records 
of the most important matter in all this work, cure and pre- 
vention. 

(Our estimate is 7 cases in a thousand.) 

8, GLANDS ENLARGED, ADENITIS, TUBERCULAR LYMPH 

NODES 

This is another ailment quite common to children and 
which may lead to serious consequences, the least of which 
may be, if Ayres' findings * are true, serious retardation in 
school, amounting to a loss of 1.2 years in passing through 
the elementary school. Other causal factors operate, how- 
ever, with such cases and we are not sure that the retardation 
may not have been due in whole or in part to poverty, bad 
heredity or some other associated cause. Verification of such 
studies lies in the future. 

Malnutrition, bad ventilation, and decayed teeth are 
named by physicians as causes of this ailment, though they 
give but little scientific proof of their conclusions. One very 
clear route of travel to adenitis seems to lie through the 
following steps : decayed teeth, enlarged tonsils, adenoids 
and indigestion, then enlarged glands. Frequently the route 
is also up the eustachian tubes to otitis media, or discharging 
ears and deafness. The glands may also become tubercular 



*Laggards, page 128, and the 19 13 edition of Medical Inspection 
of Schools, page 161. 



AILMENTS OF SCHOOL CHILDREN 171 

and consumption may follow. The mouth Is the portal. 
Much of medicine, as of education, is, however, yet a matter 
of mere hypothesis. 

So few of the gland cases are recorded as treated or 
cured that a separate column is not given to these data m the 
table. Something of the frequency of the ailment may be 
gleaned from the data below : 

ENLARGED GLANDS 

Per- Re- Reported 

Cases. centage. ferred. Treated 

Summit 1,034 Exam'd. ^03 lO.o 

S. Manchester 1,725 Exam'd. 2 .1 2 

Norwood 1,571 El. Pup. 8 -5 » 

Winchester 1,505 El. Pup. 18 2.3 18 

Montclair 3,255 El. Pup. 25 .8 25 

Hoboken 8,773 Exam'd. 5 .0 5 

Schenectady 10,121 El. Pup. 29 .2 

Waterbury 12,077 El. Pup. ^H -9 

Yonkers 3 -O 

New Bedford 11,839 El. Pup. 15 -i 

Trenton 10,587 Exam'd. lO .1 

Cambridge 15,445 El. Pup. 30 -2 

Syracuse 18,016 El. Pup. 39 -2 

Rochester 15,157 Exam'd. 1281 1.2 

Providence 31,946 El. Pup. 70 -2 

Newark 24,310 Exam'd. 4^47 ^-7 

Boston 61,055 El. Pup. 700 I.I 

Average 1.2 per cent for 15 cities. 28.6 percent. 

Here we have percentages of this ailment far below on 
the average those usually given. In the controlled investiga- 
tion by Ayres in 1908 previously mentioned, among 7,608 
children medically examined, a percentage of 40 P^r cent 
were found suffering from enlarged glands in the six-year 
group and 7 per cent in the 15-year age group. The per- 
centage for all is not given. Among 3,304 of those above 
the age of nine especially studied, over 13 per cent had en- 
larged glands; and when they were divided into three classes 
the percentages were as follows: Dull, 20; Normal, 13; 
Bright, 6. 

None of the figures in these twenty-five cities approach 



10 .1 10 

30 



172 SCHOOL HEALTH ADMINISTRATION 

very closely to this average. The conclusions which might 
be drawn to account for this discrepancy are : 

a. Summit and Newark were the only cities which made 
very thorough examinations of the children. There is some 
truth in this. 

b. These cities have not found all the cases. There is 
also some truth in this. 

c. The New York children are more afflicted with this 
ailment. I doubt whether there is very much truth in this. 

d. The New York physicians found more cases than 
there were, or called very slight deviations from the normal, 
enlarged glands. If there is much truth in the last hypoth- 
esis, Ayres' findings rest on a very unstable basis. The time 
is not ripe to be dogmatic in this field. 

In the entire city of New York in the school year of 
1910-11 among 230,243 children examined, only 483 cases 
were found, a percentage of .2, the average above given. 
The 19 1 2 monograph on "The Division of Child Hygiene," 
of the Department of Health of the City of New York, 
shows also no great variations by ages, as shown on the 
chart, part 82. The percentages for 19 10 and 1909 are 
practically .3. These figures throw more suspicion upon the 
accuracy of the Ayres' data. 

What general statement of the prevalence of this defect 
can we derive from the above data ? Some cities apparently 
found, or at least recorded, no cases at all. One would not 
expect to find a high percentage of these cases in Summit, 
it being probably one of the most healthful and generally 
well-to-do of the cities, a suburban resident town. There 
seems, however, to be little sociological basis for the varia- 
tions, the mill towns and others with congested foreign 
population not standing very high, comparatively. The 
length of time medical inspection has been in force seems to 
make no difference. The difference must lie more in the 
standards, requirements, and interests of the men and women 
making the examinations and inspections. 

Special studies in England of some 10,000 children place 



AILMENTS OF SCHOOL CHILDREN 173 

the percentage of cases below one per cent as in most of 
the cities in this investigation.* 

The number of cases in Summit was very much smaller 
the year before the above report, the exact figures not being 
given; but among 950 pupils examined there are only 91 
(about 10 per cent) miscellaneous cases of "anemia, mal- 
nutrition, coughs, colds, nervous affections, glandular swell- 
ings, etc." Undoubtedly, the percentage was very low; and 
yet the Ayres' figures for the retarding effect of glands are 
given in the same report. In the later report studied, 
1910-11, the doctor says in his report, "Glands — Particular 
attention was paid to enlarged glands of the neck. These 
usually accompany decayed teeth and are apt to break down, 
or become tubercular unless prophylactic treatment is given. 
There were 103 cases." None were referred according to 
the following statistical table in the report. This is a glaring 
example of a point made by the writer on a former page, that 
physicians find what they give "attention" to, what they look 
for; and the Summit physician Is quite above the average 
medical Inspector. 

Discounting, then, very much the Summit percentages, 
we have Newark to consider. The previous report shows 
a percentage of 16 for this defect. My judgment is that 
very slight deviations from type for this defect are recorded, 
rather than that the children are especially ailing in this 
particular. Then, too, many children not among the 24,310 
examined, undoubtedly furnished cases. The probabilities 
are that the true percentage Is not above four per cent at 
most. Trenton and Rochester both had physical examina- 
tions and their percentages are only .1 and 1.2. 

Taking a number of such facts Into consideration we 
should estimate that the actual number of cases in the ele- 
mentary school populations serious enough to warrant atten- 
tion and preventive or curative measures Is around one per 
cent, as a fairly generous estimate. Not until there is some 



*i9io report of the Chief Health Officer of the English Board of 
Education, pages 53 and 54. 



174 SCHOOL HEALTH ADMINISTRATION 

adequate standardization of reporting this and other ail- 
ments through the training and supervision of physicians 
and nurses will there be much correspondence among reports. 

9. HEART DEFECTS, HEART DISEASE, CARDIAC AILMENT 

The 191 1 report of the Board of Education of England 
above mentioned summarizes the situation here with respect 
to this ailment, in the following words: "As far as can be 
judged from the attention bestowed on this subject in the 
reports of School Medical Officers, it does not appear as 
yet to have aroused widespread interest or to have formed 
the basis of many special inquiries" (page 54). We have 
nothing in America comparable to this report, however. The 
percentage of children affected seems to be about one per 
cent. 

Without placing here all the figures, the reasoning and 
the guessing necessary, we shall give in this and several other 
cases only the probable frequency of the ailment, with the 
variabilities. 

Some of the cases are: Summit, .3 per cent; Boston, .2 
per cent; Rochester, .5 per cent; Newark, i per cent; Tren- 
ton, I.I per cent; Hoboken, 1.4 per cent. In New York City 
in 191 1, the percentage is .7. The average for our cities is 
less than .7. 

Discounting for recording very minor cases, and adding 
for the cases missed, we judge that the number of the vari- 
ous kinds of heart defect needing attention and treatment is 
between .6 and 1.2 per cent, say .9, to name a figure. With 
better education in this respect, and all examinations made 
with the pupils' chests stripped, the percentage of real cases 
will probably rise to one per cent. Most cities do not have 
the latter necessity for adequate heart and lung examinations. 

10. LUNGS WEAK, NOT TUBERCULAR 

Some children are flat chested, weak lunged and predis- 
posed to pulmonary troubles, but not yet infected with tuber- 
culosis. They need good ventilation, physical training in the 
form of plays and games and probably medical gymnastics, 



AILMENTS OF SCHOOL CHILDREN 175 

light work, good food and general care. These are the ones 
who are anemic and debilitated, and frequently, if not 
always, profit in an open air school. We can tell little about 
the frequency of the defect. Depending again largely upon 
cities that have physical examination, we have an average 
percentage of about .5 or a half a per cent, five cases in a 
thousand. This is only a guess because the defect cannot be 
well defined. 

II. MALNUTRITION, DEBILITY, INDIGESTION, GENERAL CON- 
DITION 

These ailments are not well differentiated, but they are 
not separated well in the reports. Debility and indigestion 
may have little or nothing in common with malnutrition. 
The latter term is most commonly represented in this col- 
umn, however. 

The percentages for some of the cities are as follows: 
Summit, I per cent; Norwood, i per cent; Montclair (many 
cases of "general condition"), counting 124 cases, 4 per cent; 
Hoboken, .05 per cent; Waterbury, say 30 cases, .2 per cent; 
New Bedford, .4 per cent; Trenton, .4 per cent; Cambridge, 
.1 per cent; Rochester, 5 per cent (these doctors also visit 
those families who are ill and in poverty; and this may ac- 
count for the attention given to malnutrition) ; Providence 
(100 cases), .3 per cent; Newark, 2.6 per cent, and Boston 
(counting 800 cases), 1.3 per cent. The average is 1.3. 
The median is 4 per cent. 

There are undoubtedly very many more cases of under 
and poorly fed children in many of these cities, as could be 
easily determined on investigation, probably as many as six 
or seven per cent in some cities with more poor and more 
foreigners than Rochester. This problem very much needs 
scientific study, and school systems very much need adjust- 
ment to the situation as found. England is far ahead of us 
in this particular. Both the 19 10 and 19 11 English reports 
mentioned give able treatments of this matter. Among 
about 200,000 children examined * in counties and urban 
districts, approximately 20 per cent were regarded "good" 

*I9II Report. 



176 SCHOOL HEALTH ADMINISTRATION 

as to nutrition, 69 per cent "normal," 10 per cent "sub- 
normal," and a little less than one per cent as "bad." These 
percentages are based upon the medical judgments of the 
physicians. Attempt at objective standardization of the 
examination is being made in the relationship to height and 
weight, pages 27-29. 

A "nutritional index" was worked out, namely: Index 
equals 100 times the cube root of the quotient of the weight 
in kilograms divided by the height in kilograms. 

The average value of this index for each year of school 
age from three to fifteen for 9,166 children examined was 
determined, and these standards used for measuring the 
nutritional condition of various groups of children, with fair 
results. 

The London County Council publishes a book largely 
given over to the problem of meeting the malnutrition sit- 
uation (Handbook Containing General Information with 
Reference to Children's Care, second edition, R. Blair, Edu- 
cation Officer, London). 

In our own country, and among these cities studied my 
judgment is that not far from two per cent of the elementary 
school children are suffering enough from malnutrition to 
need special care and treatment. In New York City, the 
percentage is from 2.5 per cent to perhaps 3.5 per cent. 

12. DEFECTIVE MENTALITY, BACKWARD CHILDREN 

Only half of the cities mention this serious defect. Provi- 
dence has since employed a neurologist for the examination 
and study of such cases, but further than that there seems 
to be no specialization of this function as at Cleveland, Los 
Angeles and other places. 

Some of the percentages of this ailment are as follows : 
Summit, I per cent; Norwood, 5.4 per cent; Winchester, .1 
per cent; Montclair, 1.5 per cent; Schenectady (47 cases), 
.5 per cent; Waterbury, .1 per cent; Trenton, .1 per cent; 
Cambridge, .1 plus; Providence, .2 per cent, and Newark, 
1.4 per cent. The average is for these ten cities, .9. This 
Is practically the number found In Cleveland by the psy- 



AILMENTS OF SCHOOL CHILDREN 177 

chlatrist with the help of the Binet tests, but according to 
the 191 1-12 report, page 3, "falls far short of the total num- 
ber in the public schools." A distinction is made between 
the feeble-minded and the mentally defective children, "the 
epileptic children should also be included in the group to be 
eliminated" from the schools. This would raise the percent- 
age for Cleveland (750 cases and 41,514 examined by doc- 
tors) up to 1.8 per cent. Dr. Holmes of Newark also urges 
the elimination of all such children from the schools. Dr. 
Goddard in his investigation of this problem for the School 
Inquiry Committee, concluded that there are at least 15,000 
feeble-minded children in the public schools of New York 
City, about 2 per cent. These are children "so mentally de- 
fective as to preclude any possibility of their ever being made 
normal and able to take care of themselves as adults." This 
is also the percentage found among 2,000 children in the 
little town of Camden, N. J.* 

Our judgment for these cities is that the actual per- 
centage of mentally defective children in the elementary 
schools is not far from one per cent. 

13. NERVOUS AILMENTS, CHOREA, HABIT SPASM, NERVOUS 

EXHAUSTION 

There are a number of ailments of the nervous system 
which are frequent among children, and important from the 
educational point of view. These are well treated from 
the medical point of view by Cornell and Hoag in their 
books on "Medical Inspection" and the "Health Index." 
We are concerned here principally with their frequency and 
administration. Some of these ailments connected with 
speech, sex, etc., are treated in other columns. The prin- 
cipal ones here are chorea, or St. Vitus' dance, a nervous 
twitching of various muscles of the neck, face, head, shoul- 
ders, arms and legs. Dr. L. D. Cruickshank, in his most 
excellent "Sixth Annual Report on the Medical Inspection of 
School Children in Dunfermline," Scotland, says it is "re- 



*See Pedagogical Seminary for June, 191 1, "Two Thousand Chil- 
dren Tested by the Binet Scale," by Henry H. Goddard. 



178 SCHOOL HEALTH ADMINISTRATION 

garded by some as a manifestation of rheumatism and as 
such requires special care in order that no damage may result 
to the heart. Children should come under treatment as soon 
as the choreaic movements are detected. Continuance at 
school is harmful even when the symptoms are slight in 
character." 

Nervous exhaustion is found more particularly among the 
girls in the upper grades and high school. Nervousness, ex- 
citability, and peculiar nervous habits all come under this 
list. Epilepsy is included, but would not have been had there 
been many cases reported (13 in Boston). A few other 
ailments have very small representation. The chapter by Dr. 
Cornell in his book, pages 324 to 358, is probably the best 
school discussion we now have of the trouble. Reports from 
some of the cities are as follows : 

Summit 8 cases, a percentage of about i per cent 

Montclair 20 cases, a percentage of about .8 per cent 

Hoboken 4 cases, a percentage of about .04 per cent 

Brockton 17 cases, a percentage of about .2 per cent 

Waterbury .... 6 cases, a percentage of about .06 per cent 

Trenton 8 cases, a percentage of about .07 per cent 

Cambridge 14 cases, a percentage of about .09 per cent 

Providence .... 134 cases, a percentage of about .4 per cent 

Newark 77 cases, a percentage of about .3 per cent 

Boston 130 cases, a percentage of about .2 per cent 



3-17 
Average, .3 per cent. Median, .3 per cent. 

The percentage in Dunfermline is .4 per cent. In New 
York City, the percentage is also .4 per cent. Better medical 
examination and inspection in our upper grades and high 
schools will undoubtedly raise this percentage. My judg- 
ment for the elementary schools of the cities is that its fre- 
quency is at least .5 per cent. Dunfermline has more careful 
work than any public school system in this country, probably, 
but its examination system is so arranged that all pupils are 
not examined each year. If the whole school system were 
covered each year by thorough examinations, the percentage 
would probably be raised. For serious cases, the percentage 
is probably less than .2. It can be seen from this that many 



AILMENTS OF SCHOOL CHILDREN 179 

cities have not found the cases. When the attention of medi- 
cal men and nurses is drawn to the importance of this ail- 
ment and its prevention, the figures will very rapidly 
climb up. 

14. PALATE DEFECT, CLEFT PALATE, ETC. 

Cleft palate is associated with hare lip. The high, nar- 
row palate is associated with enlarged tonsils and adenoids. 
Fortunately, the ailment is uncommon, only seven cities 
mentioning it, and three of this number with only one case. 
It might be placed with the Orthopedic defects, or "De- 
formities." The percentage for Cambridge is .05 ; for 
Rochester, 1,7; and for Newark, 1.7. It is not mentioned 
In either Boston report. The average proportion is probably 
seven cases in a thousand. 

15. SKELETON DEFECTS, ORTHOPEDIC, DEFORMITIES. 

Spinal curvature (scoliosis), round shoulders, and the 
like, are given separate space in the next two columns (89 
and 90), because of their importance in school life. In cer- 
tain cases spinal curvature was given with other deformities 
and is here included. They should be kept separate. Pigeon 
breast, caused, like scoliosis, quite largely by rickets in in- 
fancy, wryneck, webbed fingers and toes, flat feet, and a 
number of others come in this list. 

The frequency is about .2 per cent, or less. 

In the case of this and the following group of ailments 
we have the province of medical gymnastics, or therapeutic 
exercises. In the School Clinic at Dunfermline, previously 
mentioned, there is a separate division with an expert in 
charge for all such work. Through massage, carefully 
guided exercises, and general hygienic regimen much which 
cannot be surgically or medically cured, can be helped, and 
Improved. 

16. SPINAL CURVATURE, POSTURE, ROUND SHOULDERS, FLAT 

CHEST 

The lack of sufl^cient medical examiners and the peculiar- 
ities of public opinion, or public sentiment, are such that 



i8o SCHOOL HEALTH ADMINISTRATION 

genuine, all-round physical examinations are not yet being 
made in American public schools. To discover and study 
such defects as are here listed means the removal of the 
child's clothing, or at least stripping to the waist. This is 
now practiced in the best private and normal schools, and 
colleges. A very few cities are introducing such examina- 
tions in the high schools; and some courageous medical ex- 
aminers go ahead and do their work in a thorough way in 
the elementary schools. In certain or all cities there are 
school districts in which anything necessary for scientific 
work can be done, and in others, generally the richer and 
supposedly more enlightened, the policy is more that of 
"hands off." Yet the children of the latter are frequently 
the ones who need most attention of this kind. 

The frequency in the elementary school population is per- 
haps not far from .8 per cent, and perhaps one per cent. 

Dunfermline has 2.2 per cent well marked cases of spinal 
curvature (97 cases and 4-A9'^ pupils examined). Evidently 
here there were adequate examinations, slight deviations re- 
garded perhaps, and a greater prevalence than in this coun- 
try; although we may have more cases than even one per 
cent. 

Fundamental prevention of this ailment must begin in 
the child's infancy through the preventing of rickets and 
such ailments. 

17. SPEECH DEFECTS, STUTTERING, STAMMERING, LISPING, 

LA L LING 

Stammering or stuttering is the commonest of these ail- 
ments. "The condition is commonly the result of imitation, 
and this gives rise to a difficulty in treatment, because stam- 
merers are likely to increase each other's defects when placed 
in special classes." These words by Dr. Cruikshank may 
be too strong against class treatment; for pupils imitate and 
start the habit only when they think it is smart, but when 
there is a good deal of social disapproval or stigma upon it, 
the danger of imitation seems to be slight. The new book 
by Professor Scripture on "Stuttering and Lisping" marks 



AILMENTS OF SCHOOL CHILDREN i8i 

an epoch In the scientific diagnosis, treatment and prevention 
of this distressing ailment. 

Only 433 cases were reported by the physicians in all the 
cities. 

In Newark, the percentage of such cases among the 
children examined is nearly 1.7. In Dunfermline, the per- 
centage is about the same. Exceedingly few cases are men- 
tioned In the 24 other cities outside of Newark. Probably 
less than one per cent are affected the country over. We 
place it .9 per cent, to give it definlteness. 

This concludes physical defects according to our classi- 
fication. A later table will show the percentages for all 
the ailments, and the probable number of cases among the 
elementary school children In all the cities taken together, 
and comparing them with the cases actually reported. 

There are undoubtedly very Interesting and important 
individual variations among the cities In the number of cases 
of the various ailments actually existent; but the personali- 
ties, standards, equipments, and methods of the workers 
in the school health service are at present so varied that 
the real health variations can hardly be disclosed. This 
remains for the future. Summit, Winchester, Montclair 
and other cities of a suburban character should show very 
different findings from Lowell, Hoboken, Jersey City 
New Bedford and foreign factory cities generally. Such 
sociological differences do not as yet appear. 



CHAPTER SEVEN. 
COMMON NON-INFECTIOUS AILMENTS 

B. Common Non-Infectious Ailments 

1. ABSCESS^ BOILS, ETC. 

This class of ailments is very infrequent and perhaps 
should be placed with wounds, sores, etc. If properly cared 
for by the nurse, boils, carbuncles and other similar infec- 
tions may easily be classed with the other first-aid treat- 
ments. Separate place is given here because it is mentioned 
separately so many times in the reports of 12 cities. All 
persons who have had these troubles can sympathize with 
the children and realize that their lives can be filled very 
full of suffering from such infections. The percentage of 
cases is very low, probably near .2 per cent. Boston reports 
314 cases, or .5 per cent of the elementary school enroll- 
ment. 

2. ACUTE SORE THROAT 

Sore throat is quite common among children and as a 
term is better than more technical ones. Perhaps both 
laryngitis and pharyngitis, mentioned practically only by 
board of health physicians, could also be included in this 
term, although, in general, accuracy of diagnosis and de- 
tailed statement mean more scientific procedure. 

Sore throats are so closely associated with a number of 
infectious diseases that in some towns, such as Montclair, 
the nurse makes a practice of taking a swab from the 
throat of almost every child severely affected. The child 
is first temporarily excluded; the nurse goes to the home 
with the child, takes the swab, and instructs the mother 
in the care of the child. When the culture has been made 
at the drug store or Board of Health office, the nurse knows 
whether the child should be excluded and turned over to 

182 



NON-COMMUNICABLE AILMENTS 183 

the Health Department as a diphtheria or other case. Noth- 
ing less than this procedure seems to be sufficient to exclude 
incipient stages of several ailments which may easily become 
centers of infection, out of school if not within. (The 
researches of Dr. Chapin at Providence make it doubtful 
whether there is very much spread of infection at school, 
191 1 report.)* The frequency of the ailment will prob- 
ably vary, as will most of the ailments in this class, more 
than the physical defects, which seem to be remarkably 
constant, depending more upon the weather, home and 
school ventilation, and the like. 

The percentage of cases during the school year is prob- 
ably near .2. Boston has .5 and Newark .05 per cent. 

3. BRONCHITIS 

This ailment is quite infrequently reported or found. 
Less than half of the cities mention It. Generally the case 
is not found In school, and Is only reported after the child 
has returned. It seems certain that an adequate and sci- 
entific administration of this work will, by the way, neces- 
sitate fairly complete health histories of the children in 
school and out. The child who is absent with bronchitis, 
for example, should be visited by the nurse and Inspected 
on his return and a record of the ailment made. Common 
ailments are now much neglected. If the school medical 
service is ever to develop Into what it should become, a 
preventive as well as a curative agency, the causes as well 
as the cases of all these common ailments which so much 
lower the vital efficiency of children will be matters of 
careful study. 

The frequency of bronchitis Is as follows : Boston, say, 
300 cases (for the nurses undoubtedly found a number of 
new cases), .5 per cent; Lowell, .2 per cent; Trenton, .1 
per cent, and the others less. 

The frequency is at least .1 per cent. 



*See also Professor Jordan's article in the 1912 N. E. A. report 
on School Diseases. 



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NON-COMMUNICABLE AILMENTS 187 

4. CLEANLINESS NEEDED 

The great enemy of health is filth, and, along with fresh 
air, exercise, and nourishing food, cleanliness constitutes 
one of the great preventive methods. Dr. Cruickshank, 
in his 1911-12 Dunfermline report previously mentioned, 
adequately sums up the matter (page 109) in these words: 

"On looking through the report one cannot help being 
impressed by the number of children suffering from dis- 
eases which ought to be — which indeed are preventable. 
And when we analyze the causes of the various diseases 
and defects and seek some common factor operating in 
every case we find it in the environment. But environment 
itself is so complex that we must seek for some common 
factors in it which specially influence the health of tender 
child life. Of these factors there are several, but the most 
important are dirt and foul air. hack of cleanliness, per- 
sonal and otherwise, and absence of fresh air, are probably 
accountable for more diseases than all other factors to- 
gether. Frequently they are the direct cause, as in certain 
inflammations of the eyes and skin, frequently the indirect 
cause, as in many cases of malnutrition and tuberculosis." 

The schools must fight filth as the arch-fiend. 

The details regarding school baths, compulsory and en- 
ticed cleaning, and the like will be set forth later. 

Some of the cities do not mention this condition or ail- 
ment; Boston mentions it in neither the health nor the school 
department reports. None of the cities are equipped at 
the schools for providing adequate school cleaning, and it 
is a waste of energy to tell a child to bathe at home when 
there is no bathtub there and his parents have never prac- 
ticed this element of civilization, frequent bathing. Shower 
baths and swimming pools are essential to the cleanliness 
of the child population. Rigid treatment will in most cases 
procure for the children clean underclothing and other gar- 
ments, and the teacher can look out for faces and hands. 
Some persons advocate hot and cold water wall-washbowls 
in each class room not only for the purpose of aftording 
drinking water by means of a sanitary drinking fountain 



1 88 SCHOOL HEALTH ADMINISTRATION 

and water for drawing work and cleaning the blackboards 
and watering flowers, but also to help develop the personal 
cleanliness habit. 

Great tact and care is, of course, required of the school 
nurse and teachers, but the matter can hardly be overem- 
phasized from the health standpoint. 

Some of the frequencies for uncleanliness are as follows : 
Summit, 2 per cent; Norwood, 1.3 per cent; Winchester. 
.5 per cent; Montclair (estimate, 35 cases), i per cent; 
Yonkers, .3 per cent; New Bedford, .2 per cent; Provi- 
dence, .3 per cent; Jersey City, .2 per cent; Newark (45 
cases), .2 per cent. This is an average percentage of .6. 

Considering the fact that many cases are not recorded, 
and that in some of these cities, such as Providence, the in- 
spection covered only a part of, or very inadequately, the 
elementary school population, and that these figures where 
there were no examinations are based upon enrollment and 
not average attendance, we should probably find that at any 
one time from one to two per cent {say one) were in need 
of immediate cleaning (bathing and clean clothes, not to 
mention vermin) in order to make them sanitarily whole- 
some members of a classroom. The physician in Summit, 
in a first-class suburban city, found a higher percentage of 
cases, I believe, because he was more sensitive to this condi- 
tion, took a more energetic attitude toward the treatment 
of such cases, or kept better records of the work done. The 
physician who is director of hygiene at Cambridge has de- 
vised a nozzle for a hose by which he washes down ten to 
fifteen boys at a time to their and their teachers' delight. 

We give below the summaries of two of the four tables 
on Cleanliness given in the 1911-12 report of Dunferm- 
line, Scotland: 

Number of children examined, ages 4 to 14 and over, 

999 boys and 828 girls. 

Per cent. Per cent. 

Boys. Girls. 

Cleanliness, "Good. Above average percentage." 58.15 69.41 

Cleanliness, "Medium. Average percentage." 37-73 29.35 

Cleanliness, "Bad. Below average percentage." 4.10 1.23 



NON-COMMUNICABLE AILMENTS 189 

The girls are cleaner than the boys, although, as shown 
in other tables, with their long hair they suffer more from 
pediculosis which may also be looked upon as uncleanliness. 

Other tables show that boys are very much dirtier at 
the age of eleven, than at any age before, while girls grow 
cleaner. 

Percentage of children marked "bad" as to cleanliness in 
Dunfermline, Scotland, 1911-12. Children examined, 999. 

Per cent. Per cent. 

Boys. Girls. 

Infants examined for first time, average age, 6 years. ... 1.62 1.22 

Examined entering Senior School, average age, 8 years... 3.1 1.23 

Third examination, 11 years 5.55 i.oi 

Fourth examination, leaving school, 14 years 1.5 1 .... 

The director of hygiene points out the fact, too, that 
parents, on receiving the notice of, and the invitation to 
the examination of their children get them in clean condition 
for it. "Parents receive notice of the intending examina- 
tion, and frequently prepare the children for it. The figures 
returned from the School Medical Officer's examination 
will therefore always show a condition of things better than 
actually exists" (page 30). 

If physicians and nurses in this country tabulated their 
findings and made as careful studies of their children as 
these figures indicate it is very probable that our larger 
estimate of two per cent of all elementary school children 
would not be too large. 

5. CATARRH, CHRONIC RHINITIS, COLUMNS IO3-4 

Chronic bad cold and "running nose," resulting from 
sitting In school with wet feet, bad ventilation at school or 
home, or some other single or combination of causes, is a 
more serious and common ailment than Is generally realized. 
Most of the cities that have much to report at all regarding 
the health conditions of the children In general, and not 
merely from one particular aspect, say Infection, report 
some cases. The number of cases found will depend upon 
the time of year the examination or the Inspections take 



I90 SCHOOL HEALTH ADMINISTRATION 

place since many cases may remain undetected until bad 
weather or other untoward conditions bring them out. 

The Dunfermline report previously mentioned has this 
to say regarding catarrhal conditions in connection with 
adenoids: "Adenoids are clearly associated with catarrhal 
conditions of the naso-pharnyx. As these conditions are so 
very prevalent we must continue to expect large numbers 
of children to suffer from this disagreeable and harmful 
condition. It is quite probable, however, that pure air in 
the schools, instruction in the use of the handkerchief, and, 
when adenoids are suspected, the daily practice of nasal 
respiratory exercises, would reduce the frequency of opera- 
tion for this condition to a minimum" (page 35). 

Some of the frequencies are as follows : Trenton, 2 
per cent; Summit, 7 per cent; Hoboken, only 3 cases re- 
corded; Rochester, with over 15,000 pupils examined, 
records no case; Yonkers, i per cent; Cambridge, 2 per 
cent; Newark records no cases and no other ailment whict^ 
seems to cover this condition unless it could be placed with 
adenoids, which is unlikely; Boston (327 cases), .5 per cent. 
Here we have an average for the cities mentioning the 
most cases an average percentage of .7. The frequency 
must be almost that of cleanliness, one or two per cent, say 
one per cent. How many cases the various cities missed, 
judging that the actual variations as among cities is not 
great, can be seen by comparing the figures given, reduced 
to percentages, with this standard. Boards of Health, as 
with most other diseases, have a bad showing. 

6. BAD COLDS, CORYZA, COLUMNS IO5-I06 

In this list are those severe, comparatively non-infectious 
colds which are so frequent among children and which en- 
tail such severe consequences. Probably all colds are more 
or less infectious. Hoag, in his "Health Index of Chil- 
dren," page 50, says they are the most infectious of all 
ailments: "Colds are probably about the most contagious 
form of disease we have, yet many, if not most people still 



NON-COMMUNICABLE AILMENTS 191 

go on regarding them as due to drafts, getting wet, to 'night 
air' and similar delusions. As a matter of fact anything 
which is capable of reducing our resistance makes it easy 
for cold germs to gain the ascendancy, but the cold is di- 
rectly due to the germ or germs, and these causes should 
not be confused with the predisposing factors." 

Since "a cold can always be laid to someone else," as 
seems probable, it should, perhaps, be treated as an in- 
fectious disease of the minor group, instead of in this place. 
We give place here for it, because no city of which I know 
places it in the infectious group. I leave place for it also, 
however, along with influenza and grippe. The future will 
probably bring about a handling of "bad colds" the same 
as other infectious ailments. 

Nurses mention this ailment in but four cities and the 
physicians in but one. Both the health and the school de- 
partments record it as Coryza in Boston. The frequencies 
are as follows: Norwood (50 cases), 3.2 per cent; Win- 
chester (33 cases), 2.2 per cent; Montclair (108 cases), 
2-2 per cent; Boston (400 cases), .7 per cent. 

The average percentage of elementary children is, there- 
fore, 2.7 per cent. Undoubtedly, the ailment occurred with 
the same or greater frequency in all cities but was not re- 
corded. The inadequate medical staffs found that they had 
far more than they could do with the most serious and even 
death-dealing diseases, to pay any attention to these minor 
ones which so frequently bring on the greater. If we are 
going to make medical supervision what it should be, a 
means of scientific prevention as well as cure, however, these 
cases of coryza or bad cold will receive attention and study. 

Our estimate of this ailment, counting only cases which 
should probably be out of school, or at least receiving care- 
ful treatment, Is at the lowest, three per cent. It Is probably 
not less frequent In high school. Rather Infrequent Inspec- 
tion at the Montclair high school seems to show this. 

These are regarded as separate and distinct cases, al- 
though we have here an ailment which may come upon a 



192 SCHOOL HEALTH ADMINISTRATION 

child more than once in a school year. Perhaps, too, not 
less than three per cent of the school children are affected 
with bad colds at some time in the year. Those experi- 
enced in the classroom would probably place the estimate 
very much higher. 

7. EAR DISCHARGE, OTITIS MEDIA, RUNNING EAR, OTOR- 
RHEA, COLUMNS 107-108 

Here we have a serious ailment closely connected with 
deafness and adenoids. Starting from bad colds and nasal 
catarrh, along with adenoids and perhaps enlarged tonsils, 
we get an inflammation which travels up the eustachian 
tubes and sets up a suppuration in the middle ear which, 
breaking through the ear drum, pours out along the channel 
of the outer ear, a most distressing condition. If not cared 
for the ailment may spread into the mastoid bone back of 
the ear, making necessary operations for mastoiditis. 

The treatment takes a long time, generally, and nothing 
short of a first-class school clinic will meet the situation for 
most children. Sixty-seven cases made 3,074 visits to the 
school clinic in Dunfermline, Scotland, an average of about 
46 visits each, and probably not all of these cases were cured 
at the time of reporting. 

A medical inspection system which neglects this ailment 
Is either derelict In Its duty, or very far short of what the 
school medical service should be. 

Seven cities in this group of twenty-five have made no 
record of such cases, either by nurses or physicians. Jersey 
City records but 3 cases, excluded. About how many cases 
there actually were can be estimated from the following 
percentages : 

Frequency of Ear Discharge among elementary pupils: 
Summit, .6 per cent; Norwood, .2 per cent; Winchester, 1.8 
per cent (27 cases) ; Montclair, .3 per cent; Schenectady, 
2.2 per cent; Waterbury, .2 per cent; Yonkers, .8 per cent; 
New Bedford (no cases), .9 per cent; Trenton (among 
10,587 pupils examined only 7 cases) ; Cambridge (69 
cases), .4 per cent; Providence, .4 per cent; Newark (24,310 



NON-COMMUNICABLE AILMENTS 193 

children examined, only 31 cases), .1 per cent; Boston (425 
cases, counting new cases found by nurses), .7 per cent. 
Average percentage, .7 per cent. 

Among 1,812 children ranging in age from four to 
above 14, in Dunfermline, there were 37 cases of "purulent 
discharge," and 15 cases of "old discharge," percentages of 
2 and .8. This percentage of 2 seems to be about the num- 
ber we should find here if we were to have more careful 
examinations of all children. This will vary with the cities 
somewhat, undoubtedly, but, I feel sure, much more because 
of the differences in the doctors and nurses. Many of the 
cases, moreover, have no actual discharge at all, and yet are 
serious enough to cause partial deafness. 

The 19 10 report of the Board of Education of England 
on this subject (page 48) gives the following summary of 
a table showing the relation of ear discharge to defective 
hearing and adenoids and tonsils : 

Number children with defective hearing, all ages 44i 

Proportion of these cases due to: 

Middle ear disease with discharge i4-0% 

Middle ear disease without discharge generally associated 

with enlarged tonsils and adenoids 65.7% 

Ceruminous obstruction (ear wax) 20.1^ 

99.8/0 

According to this report, we should judge that about 80 
per cent of deafness comes from this ailment. We found 
that the probable proportion of defective hearing was about 
one per cent. This would show that middle ear disease was 
more frequent than one per cent. We do not have recorded 
here the number of cases with no associated defective 
hearing. 

In the 191 1 report of the same health officer (Sir Geo. 
Newman, London) we have another summary of several 
tables, page 44, which throws more light on this ailment. 
It is a report of the causes of deafness found among 1,265 
children aged five, and 1,352 aged 12 examined, 2,617 
altogether: 



194 SCHOOL HEALTH ADMINISTRATION 

CAUSES OF DEAFNESS. 2617 PUPILS 

Per cent. Per cent. 
Age 5. Age 12. 

Due to adenoids 78.4 52.0 

Due to suppurative otitis media (ear discharge) 15.6 38.O 

Due to suppurative otitis media and adenoids 5.8 lO.O 

99.8 100 

This shows a sUghtly different emphasis, showing per- 
haps that back of it all are the adenoids. Since adenoids 
are probably enlarged through neglected colds almost en- 
tirely, we see here a serious chain of factors which must not 
be overlooked by the school medical service. 

In summary, we should say that this is a very serious 
ailment, somewhat difficult of diagnosis, very hard to cure, 
and taking a long time, and existent among from one to two, 
say 1.5 per cent of elementary school children, more in the 
the lower grades than in the higher. This is practically 
Cornell's estimate given in his book, page 589. 

8. EARS, MINOR AILMENTS, IMPACTED CERUMEN OR EAR 
WAX, EAR ACHES DUE TO SEVERAL CAUSES, BUT FRE- 
QUENTLY TREATED BY THE NURSES, FOREIGN 
BODIES IN THE EAR, ETC. 

We have maneuvered our nomenclature to bring otitis 
media and the other ear ailments together. These other 
ailments are minor but important. We have seen the influ- 
ence impacted ear wax has on hearing, producing over 20 
per cent of the cases according to the investigator quoted, 
and the persistent earache, foreign bodies and small boils, 
and the like are no small part of a child's life, meaning, if 
nothing worse, absence from school or poor attention in it 
in many cases. Most of the cases are cases of impacted 
cerumen, although the Boston nurses reported 222 cases of 
eczema of the ear to 229 cases of cerumen and 40 of foreign 
bodies. The eczema and boils frequently come from scratch- 
ing due to pediculosis and dirt, and consequent infection. 

Only six cities mention these smaller ailments of the ears. 
Winchester mentions only two cases ; Yonkers (say 80 cases) , 



NON-COMMUNICABLE AILMENTS 195 

.6 per cent; Cambridge, .4 per cent; Lowell, .3 per cent; 
Providence, 12 cases only; Boston (229 cases, eczema cases 
put with eczema), .3 per cent. The average is .4 per cent. 
These cities did not have physical examinations, so we may 
understand that only a part of the cases among the entire 
enrolled elementary school population were found. Half a 
per cent (.5 per cent) seems reasonable for these minor 
ailments. Careful records of the whole health history of 
children will probably increase this percentage. We notice 
as we go along that those cities having the names of these 
ailments printed on the report forms get records of such 
cases, while those that have a few names of ailments which 
are very uncommonly met, e. g., tuberculosis, do not get 
them. The medical officers do not look for the ailment, or 
else fail to write it in. 

9. ECZEMA 

"Eczema is a non-contagious inflammation of the skin 
caused principally, or altogether, by disturbance in nutri- 
tion" (Cornell). There are many varieties, and many skin 
ailments are called by this name which are not true eczema. 
The ailment is handled chiefly by the nurses, and cared for 
by them, either in giving treatments or in showing mothers 
how to give them. In Newark, only the nurses mention this 
ailment, but they record 9,857 cases as treated. Whether 
this represents so many children we cannot say. 

Frequencies: Summit, .9 per cent; Norwood, .5 per 
cent; Montclair (55 cases), 1.4 per cent; Waterbury, .3 
per cent; Yonkers, .8 per cent; New Bedford, .2 per cent; 
Trenton, .3 per cent; Cambridge, .2 per cent; Lowell, .1 
per cent; Providence, .4 per cent; Newark, 45 per cent;* 
Boston (1,000 cases), 1.6 per cent (on 61,000 inspections), 
I per cent on 100,000 inspections. 



*A most astounding percentage, and probably meaning cases, with 
several cases to a child than that not far from half of the children 
examined had the ailment. The percentage would be also decreased by 
half when we consider that the nurses covered all the elementary school 
population, in a way, while the examination reached only about half. 
Leaving this at 15 per cent would be very far beyond other cities. 



196 SCHOOL HEALTH ADMINISTRATION 

The average percentage, excluding Newark, is .6 per 
cent. The actual number of cases does not probably exceed 
one per cent. Let lis say .7 per cent. 

10. EYES, MINOR AILMENTS. SORE EYES, BLEPHARITIS, STYES, 
IRITIS, CORNEAL ULCER, KERATITIS, FOREIGN 
BODIES IN THE EYE 

Here we have a host of comparatively minor and yet 
serious cases of eye ailments, mostly of the external eye. 
Some or most of these can be obviated, perhaps, by proper 
glasses, thus avoiding eyestrain and lowered resistance. We 
do not include here conjunctivitis of any kind nor trachoma, 
since they properly belong in the infectious group, and must 
receive different treatment. Blepharitis, or common sore 
eyes, is found more frequently than any other in the group, 
with styes a close second. 

The frequencies are greater than for any ailment found 
for some time, and the column showing the nurses' cases is 
well filled, showing that the nurses have handled a good 
many of them, and probably found many new cases not 
found by the doctors. 

Percentages of elementary school population or of num- 
ber of children examined: Summit, 2.3 per cent; South 
Manchester, .7 per cent; Norwood, only two cases; Win- 
chester (16 cases), I per cent; West Orange, no cases; 
Montclair (26 cases), .8 per cent; Hoboken (53 cases), 
.6 per cent; Waterbury, .4 per cent; Yonkers (234 cases), 
.2 per cent; Trenton, .3 per cent; Cambridge (54 cases), 
.4 per cent; Lowell, 1.7 per cent; New Haven, .7 per cent; 
Rochester, .3 per cent; Providence (203 cases), .7 per cent; 
Jersey City recorded only excluded cases; Newark, .7 per 
cent; Boston (1,116 cases), 1.8 per cent. 

The average percentage is .8 per cent. 

We get our surprises here from the cities that are sup- 
posed to have physical examinations, much more careful than 
inspections, but the examination cities excepting Summit do 
not show up well in this case. Some of the cities report no 



NON-COMMUNICABLE AILMENTS 197 

cases and these are either board of health cities or other cities 
starting the work and not yet well established. 

We should not expect Summit to have the largest pro- 
portion of cases, since its environment is very good and 
there is but a small foreign (Italian) section. We should 
expect these ailments in the mill and factory towns such as 
Hoboken, Jersey City, Lowell, New Bedford, Providence 
and Newark. The cases were probably there but were not 
found. 

The same conservative judgment hitherto exercised 
would lead us to estimate these ailments as existing in at least 
1.5 per cent of the elementary children at some time during 
the school year, and that the percentage of cases would be 
about two per cent. 

II. HEADACHE, NEURALGIA AND MIGRAINE 

These are symptoms, of course, but they must be treated 
as ailments by the nurses and often by the physicians because 
of inability or lack of necessity of giving a thorough diag- 
nosis. The eyes may be tested, the teeth examined, and the 
nurse can have a talk with the mother about the child's diges- 
tion and food, but even then the cause may be untouched. 

Strangely, the physicians report the ailment more than 
do the nurses, the latter in only three cities mentioning it. 
Some of the frequencies are as follows: Summit, 1.4 per 
cent; Winchester, 2 per cent; Montclair, 1.3 per cent; com- 
paratively few cases in the following cities :Newark, .8 per 
cent; Boston, .4 per cent. 

The average is about 1.3 per cent. 

For various reasons, we judge this proportion to be 
actually about 1.5 per cent to 2 per cent, say, at least, 1.5 
-per cent. Dr. Hoag reports very much higher percentages 
among the rural schools of Minnesota, but his data are ex- 
tremely poor, resulting from questioning pupils. 

12. LARYNGITIS 

Only five cities record over one case of this ailment. 
In Winchester, the frequency is 1.4 per cent; in Mont- 



198 SCHOOL HEALTH ADMINISTRATION 

clair, .3 per cent; Cambridge, .1 per cent; Providence, .07 
per cent; Boston, .25 per cent. 

The average for these cities is .4 per cent. 

The ailment is so bound up with colds, sore throat and 
the like, that it is bound to be very variable, perhaps. Never- 
theless, both departments at Boston and a number of other 
cities give it separate record, and this is probably best. We 
leave it with an estimate of five in a thousand. 

13. NOSE-BLEED, EPISTAXIS. 

Children frequently have nose-bleed and do not know 
how to stop it, using various nostrums and superstitious 
charms instead of effective means for stopping the enervating 
bleeding. 

The nurses in Boston found 136 cases, a percentage of 
less than .2 per cent. Perhaps the general proportion would 
stand near this number, .2 per cent. 

14. PHARYNGITIS, CHRONIC SORE THROAT, COLUMNS 1 2 1-2 

We get our principal notice of this ailment, also, by both 
departments at Boston. Only three other cities mention it, 
yet it is a fairly common ailment of childhood. 

Montclair had 12 cases reported, a percentage of .3 per 
cent; Trenton, .2 per cent; Boston (175 cases, counting some 
new ones found by the nurses), .3 per cent, or less. 

With little further study, we leave the estimate for future 
investigations to correct at .3 per cent — the ratio of cases 
found to the elementary school population when all children 
are carefully inspected and examined. 

15. RHEUMATISM AND "GROWING PAINS" 

Rheumatism is very serious because of its effect upon the 
heart, and the so-called "growing pains" should be carefully 
looked into. The ailment is fortunately not common. Only 
three cities mention it. The frequencies are also very low. 
One case in a thousand would probably be above the mark. 
Closer examinations will probably show, however, that .1 
per cent is not an overestimate of the actual number of cases 
among elementary school children. 



NON-COMMUNICABLE AILMENTS 199 

Every case should be carefully studied with a view to 
cure and prevention. Heart disease probably arises in most 
cases from an attack of rheumatism in childhood; and this 
is one of the greatest death-dealing diseases, standing only 
lower than tuberculosis. "It is impossible to cure organic 
heart disease, but the study of its prevention becomes one 
of the most important functions of the school medical serv- 
ice." — Crulckshank. 

16. SEX AILMENTS AND HABITS 

Very few ailments of this character are mentioned, 
largely because of the lack of searching examinations and 
careful following-up of cases. Some nurses have done splen- 
did work in this field of sex education, cure and prevention. 
Some of the ailments mentioned are: Montclair, 2 cases of 
masturbation and one of vaginitis found by a physician; 
Cambridge, 9 cases of masturbation found by nurses in care- 
ful follow-up work; the same number of cases found in 
Providence of this harmful habit; and 91 cases of syphilis 
found by the doctors in Boston. 

These findings speak well for the purity of our children 
and the homes, even though we may be sure, as is true, that 
many cases were not reported for personal reasons and be- 
cause this has not yet been recognized as a part of the duties 
of the health officers. When we have careful inspection and 
examinations and thorough follow-up work we shall discover 
much needed evidence for emphasizing in some manner sex 
education of the young. 

The syphilis cases were 1.5 per cent of the children in- 
spected in Boston. Only this one ailment is mentioned. In 
the other cities, the percentages are less than one per cent. 

Counting all cases actually present among the children 
and including the habit mentioned, certainly not less than i 
per cent are affected. 

Cornell (page 554) emphasizes knowledge: "A thor- 
ough knowledge of syphilis and gonorrhea . . . should be 
gained by teacher and high school student. Then there will 
be some hope of preventing these diseases. The salvation 



200 SCHOOL HEALTH ADMINISTRATION 

of these weakly, Infected children depends largely upon the 
recognition of the syphilitic cases by the school inspector."* 
No prudishness or sentimental false modesty must stand 
In the way of rooting out such ailments from the lives of the 
children if possible. According to the old Greeks the wise 
person is known by his hates and what he fights. Any study 
of this ailment, brought upon the innocent as portrayed In 
Ibsen's "Ghosts" and Brieux' "Damaged Goods," will 
disclose a combatant, one of the most hideous and deadly of 
civilized life. 

17. MINOR SKIN AILMENTS: HERPES, SEBORRHEA, ACNE 
(blackheads), SIMPLE RASH, POISON IVY, ETC. 

The serious skin ailments are all given separate mention. 
Here we have those frequent minor, non-infectious ones 
which furnish the nurses with so much work In the form of 
treatment and follow-up. Still certain cities do not mention 
the ailments of this group at all. 

The frequencies are as follows: Summit, .7 per cent; 
S. Manchester, .6 per cent; Norwood, 4 per cent; Montclair 
(27 cases), .8 per cent; Mt. Vernon, .3 per cent; Newton 
(49 cases), .8 per cent; Hoboken (8 cases), Schenectady 
(68 cases), .6 per cent; Waterbury, .3 per cent; New Bed- 
ford, .3 per cent; Trenton, .4 per cent; Cambridge, .9 per 
cent; New Haven, 3 per cent; Rochester (300 cases), 2 per 
cent; Providence, .8 per cent; Newark, 1.7 per cent; Boston 
(2,000 cases), 3 per cent. 

The average Is 1.2 per cent, and the deviation is large 
as In all cases where certain cities have left out all mention 
of the ailment. 

What the true percentage of new cases is we hesitate to 
judge; but leave the very tentative estimate of 1.5 per cent. 

18. STOMATITIS, MOUTH ULCERS 

Boston Is the only city which emphasizes this ailment, 



^Cornell reports also that in institutions for the feeble minded 
twenty per cent of the inmates are victims of sj^philis. 



NON-COMMUNICABLE AILMENTS 201 

although there are four other mentions of it with only 7 
cases. 

Counting the number of cases which the nurses saw, 
120, we have a very small percentage. The nurses of Bos- 
ton probably covered the entire elementary school population 
of nearly 96,000 which would give only a .1 percentage. 

We leave the probable true number of cases at this 
figure^ .1 per cent. 

This ailment might be recorded with minor skin ail- 
ments, or with malnutrition, but it will probably be best to 
give it separate mention. McCombs, in his "Diseases of 
Children for Nurses," page 99, says: "This disease is very 
common among the poorer class of patients. It is due to 
uncleanliness and to a spongy condition of the mouth seen 
in ill-nourished children. There are several varieties named 
according to the appearance of the lesions in the mouth." 

In most cities the doctors and nurses evidently miss this 
ailment. 

19. wounds, sores, sprains, chilblains, poison ivy, 
^'first aid," dressings 

Here we have a very common group of ailments where 
the nurses can be of great assistance. Children are always 
getting cut, bruised, hurt, and the like. Nose-bleed might 
also go in this group. The nurse shows the child how to 
apply principles of cleanliness and simple medicine and so 
not only saves pain and possible infections or worse, but 
educates the children in a very practical manner. 

It can be seen that some doctors and nurses consider these 
ailments within their province and some do not. Some also 
may consider them too trifling to report. However, if 
they take up time, and are worth doing, they are worth re- 
porting; and this is the more general custom. 

Eleven cities either give no mention or report exceedingly 
few cases. Eight are board of education cities and three 
are board of health. 

The larger percentages are as follows: Norwood, 22 
per cent; Winchester, 77 per cent; Montclair (187 cases), 



202 SCHOOL HEALTH ADMINISTRATION 

5 per cent; Newton, 2 per cent; Hoboken (8 cases) ; Yonkers 
(3 cases) ; New Bedford, .3 per cent; New Haven, 1.5 per 
cent; Providence, 1.6 per cent; Newark, 14 per cent; Boston, 
10 per cent. 

These variations are extreme. Large perceentages mean 
both a number of treatments of the same case, and real 
soHcitude and care of the children, most probably. 

The average for the percentages given is 15 per cent. 

This number, taking all facts into consideration, may 
probably represent fairly accurately the actual number of 
new cases among the elementary school population in any 
one year which need the attention of the nurses, and which 
may come also to the attention of physicians. 

20. URINARY AILMENTS, ENEURESIS, RENAL TROUBLE, FRE- 
QUENT REQUESTS TO LEAVE THE ROOM, INCON- 
TINENCE OF URINE 

This weakness of children is quite common but does not 
receive very frequent mention. Some selected percentages of 
cities that seem to have had their attention drawn to this 
ailment are: Montclair, .4 per cent; Cambridge, .2 per 
cent; Providence, .06 per cent; Boston, .1 per cent. 

For an estimate of little value, we place the average at 
.2 per cent as the actual number of such cases. 



CHAPTER EIGHT 

COMMUNICABLE AILMENTS, PARASITIC AND 
INFECTIOUS 

II. COMMUNICABLE, OR TRANSMISSABLE AILMENTS 

Here we enter the second grand division of ailments 
which are of a very serious character because they can 
rapidly be passed from child to child. Serious doubt is 
thrown over the old theory, that such diseases as Scarlet 
Fever and Diphtheria are propagated and diffused princi- 
pally at the schools, by Dr. Chas. V. Chapin, Superintendent 
of Health of the city of Providence, Rhode Island (Annual 
Report for 191 1 and former reports). His data, reaching 
back to 1885, also throw reasonable doubt over the theory 
that disinfection and certain forms of exclusion are neces- 
sary in the case of such ailments. We very much need rigid 
tests of all these old suppositions by scientific procedure, 
and the whole subject bristles with unsolved or untouched 
problems. The number of deaths caused by the more seri- 
ous of these ailments is given elsewhere, both for the coun- 
try, page — , and for the cities, table — , columns — .* 

The living organisms causing these ailments are mostly 
animals, but some are plants, ringworm and favus being due 
to fungi. The animals vary in size from the large and 
very common louse down to the itch-mite, almost too small 
for the naked eye, and thence rapidly down to the micro- 
scopic and almost undiscoverable germs, or bacilli, so well 
described zoologically in such books as Hough and Sedg- 
wick, "The Human Mechanism," and even Ritchie's 
"Primer of Sanitation." 



*See also the 1912 N. E. A. Proceedings, article by Professor Jor- 
dan, of the University of Chicago. 

203 



204 SCHOOL HEALTH ADMINISTRATION 

A. Parasitic and Minor Infectious Ailments 

For a long time the writer kept only the parasitic ail- 
ments in this class. They are ailments which it is the 
special duty of the nurses to drive out of existence as nearly 
as possible. But conjunctivitis, impetigo, grippe, and ton- 
silitis all seemed later to belong to this class more than to 
the serious infectious diseases which may be death-dealing. 
The advantages of such a classification need not here detain 
us. Its value will come out by use, and will stand or fall 
on how well it serves its purpose. 

I. CONJUNCTIVITIS, PINK EYE. COLUMNS I37-8 

The various forms of conjunctivitis are not differen- 
tiated here. They are very infrequently separated in the 
reports. The pupil's record card may well contain the 
specific name, but for general reporting the single term is 
probably best until the need arises for more detailed report- 
ing. The most common form is, perhaps, the "pink eye" 
which frequently plays such havoc with attendance in the 
primary grades. 

In the case of conjunctivitis, as with most infectious ail- 
ments, some cities report only the excluded cases. For the 
serious ailments this will be equivalent to the entire number 
of suspected or actual cases, but this is not true for several 
of the minor ailments. The parasitic ailment cases may all 
remain in school with-proper precautions. 

Some of the frequencies for conjunctivitis are as fol- 
lows: — The first three cities, only three cases reported; 
Winchester (15 cases excluded), i per cent; West Orange, 
3 per cent; Montclair, 3 per cent; only 9 cases in the next 
four cities; Hoboken, .8 per cent; Schenectady, 2.3 per cent; 
Waterbury, .8 per cent; Yonkers, .4 per cent; N. Bedford, 
.4 per cent; Trenton, i per cent; Cambridge, .5 per cent; 
Syracuse, .9 per cent; Providence, .4 per cent; Newark, 
1.6 per cent; Boston (1,526 cases), 2 per cent. 

The average is 1.3 per cent. Seemingly, the more care- 
ful and thorough the Inspection or examination, the closer 
the percentage comes to two per cent, or more. 






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208 SCHOOL HEALTH ADMINISTRATION 

We leave the estimate that nearly three per cent of the 
elementary school children are probably affected with con- 
junctivitis in any one school year. 

2. FAVUS, YELLOW SCALP SORES, FUNGUS PARASITE 

This ailment, while relatively infrequent fortunately, is 
yet very stubborn in resisting cure. Fortunately, also, it is 
not very infectious. 

One of the best illustrations of the tremendous resistance 
it offers to curative agents appears in the Dunfermline, Scot- 
land, report for 1911-12, previously mentioned. Three 
cases attended the school clinic for treatment during the year 
283 times, an average of 94 visits each, and even after these 
we have no statement of cure. 

Some of the other averages for visits given in this re- 
port for the ailments in this group may perhaps as well be 
stated here : 

No. of Aver. No. 

Cases. Attendances, of Visits. 

Conjunctivitis 46 455 10 

Phyctenular conjunctivitis 15 320 21 

Ringworm of scalp 26 337 13 

Ringworm of body 7 53 7 

Impetigo 223 1,127 5 

Scabies, itch 22 150 7 

Favus 3 283 94 

The average number of visits of 2,058 cases treated at 
this school clinic (14,493 visits) was seven visits. 

The English Board of Education reports also point to 
favus as being the most difficult in point of time of all these 
ailments to cure. It can be seen that a nurse could treat 
such an ailment almost every day of the school year, per- 
haps, before effecting a cure. 

Favus is rather uncommon and the frequencies are low: 
Yonkers, .3 per cent; Newark (28 cases), .1 per cent. The 
other cities stand below these figures. 

Our estimate for all cities is .1 per cent, or one case in a 
thousand. This is practically the percentage, also, for New 
York City. 



COMMUNICABLE AILMENTS 209 

3. IMPETIGO, OR IMPETIGO CONTAGIOSO 

This contagious skin disease, frequently transmitted 
through towels, perhaps, is characterized by several large 
flat scabs, or pustules which break early and form crusts. It 
most frequently appears on the face. 

Some of the frequencies are: Summit, .5 per cent; Nor- 
wood, 1.4 per cent; Winchester, 4 per cent; Montclair, 2 
per cent; Hoboken, .4 per cent; Waterbury, 1.8 per cent; 
Yonkers, .5 per cent; New Bedford, 1.6 per cent; Cam- 
bridge, .2 per cent; Lowell, .8 per cent; Jersey City, .3 per 
cent excluded; Newark, i per cent (nurses made 7,389 
treatments, and perhaps found many more new cases) ; Bos- 
ton, 2 per cent. 

The average is 1.3 per cent. Impetigo is probably more 
common than this figure represents. 

The Montclair estimate of 2 per cent seems nearer 
what may be found on careful examination of all elementary 
children in each city. 

4. INFLUENZA, GRIPPE 

Boston is the only city which gave very much attention 
to this ailment. Only six other cities mention it, with very 
few cases, some of which were excluded from school. 

The Boston percentage is .1 or .2. We cannot tell, for 
sure. The inspection really covered the entire city, and 
even the parochial school ailments are included. The num- 
ber of children was about 90,000 to 95,000. This would 
reduce Boston's percentages based upon the 61,000 inspec- 
tions. For the inspected cases were picked out by the teach- 
ers and nurses as suspected cases from the entire number. 

We leave the probable number of cases actually present 
in the elementary school population for any one year in 
the average school system at a maximum of .1. This is 
only a guess and the figure will very probably be changed 
with further investigation. 

5. PEDICULOSIS, LICE — BODY AND HEAD. COLUMNS I45-6 
This is the most frequent ailment found in the schools, 
with the exception of teeth. It can be said without qualifica- 



2IO SCHOOL HEALTH ADMINISTRATION 

tion that no other school ailment takes up so much time 
and money spent for doctors and, especially, nurses. It is 
a national disgrace, of course, that this is true ; but it is only 
by facing such facts that we shall eradicate them. Some 
cities started medical inspection for the special purpose of 
ridding the schools of this pest. The President of the Board 
of Education at South Manchester told the writer that the. 
plan was started in the hope that one year or two would 
eliminate the evil entirely. After eight years, the ailment 
is comparatively common, although reduced in frequency, 
and limited to a few families. The real remedy for such 
ailments lies in the homes. 

A girl with long hair suffering from this ailment may 
be treated and found free from pediculi or their eggs (nits) 
and called cured, and yet in a week or two be found in- 
fected again. This makes our number of cases much larger 
than the number of children affected. Just how much the 
percentages should be reduced for these considerations, we 
cannot say. It is probable that a child should be counted 
but once, no matter how many recurrences there are during 
the school year. Each of the latter can be counted by the 
nurse as inspected or treated, or both. 

The percentages for the figures as recorded are as fol- 
lows : Summit, ii per cent; S. Manchester, 4 per cent; 
Norwood, 24 per cent; Winchester, 9 per cent; West 
Orange, 4 per cent; Montclair, 10 per cent; Meriden, 7 
per cent; Newton, 5 per cent; Brockton, 15 per cent; Ho- 
boken, 4 per cent; Schenectady, 17 per cent; Waterbury, 
37 per cent; Yonkers, 4 per cent; N. Bedford, 10 per cent; 
Trenton, i per cent; Cambridge, 2 per cent; Lowell, 4 per 
cent; New Haven, 14 per cent; Syracuse, 6 per cent; Roch- 
ester, 2 per cent; Providence, 13 per cent; Jersey City, .7 
per cent; Newark, 11 per cent; Boston, 12 per cent. 

The average is 9 per cent. 

The actual number of different elementary school chil- 
dren afflicted with this ailment in any one school year is 
certainly not over 5 per cent, or one In twenty, about two 
pupils to every school room, some time in the year on the 



COMMUNICABLE AILMENTS 211 

average. The entire difficulty illustrates the practical im- 
possibility of getting accurate facts from these reports, as 
they were then and are still made up. The number of cases 
is astoundingly large, at any rate, and it is hard to believe 
that on the average about five per cent of the elementary 
school children have head lice at some time in each school 
year. (Body lice are very infrequent.) 

6. RINGWORM, TINEA, BODY AND SCALP 

This is another ailment due to a fungus vegetable para- 
site, and one which takes time and care to cure. Children 
under strict supervision and regular treatment may be per- 
mitted to attend school. The treatment in England, Scot- 
land and Germany is more efficient than in this country. 
The chief method of treatment there is by the X-rays. Diag- 
nosis is made with the help of microscopic examinations. 
The best reports of ringworm among school children are 
found in the 19 10 and 19 11 reports of the Chief Medical 
Officer of the Board of Education of England. 

We may be sure that the ailment exists in every city of 
any size, although we have cities in this list of twenty-five 
that have made no mention of It. In Summit the cases are 
not separated from other skin ailments. Scalp cases are 
more difficult to cure, and this makes desirable separate 
records of the two cases. The English report shows aver- 
age length of exclusions from school for this ailment as 
high as ten months. At Croyden, England, "the more se- 
vere cases have been dealt with by X-ray treatment for 
several years past, and the average time taken to complete 
the cure of 425 children has been 73 days, I. e., approxi- 
mately, 10 weeks." Bradford, England, seems to give the 
best general handling and treatment of this ailment. Eigh- 
teen cities or urban districts have X-ray apparatus at their 
school clinics or have portable apparatus. In several places 
ringworm classes have been established. This gives at once 
isolation from other children, and a continuance of school- 
ing. 

In none of the American cities studied in this investlga- 



212 SCHOOL HEALTH ADMINISTRATION 

tion has there been any special study and investigation of 
this ailment, of which the writer has learned. 

Some of the frequencies are : In the first five cities, 
only lo cases given separate mention, six of whom were 
excluded; Montclair (33 cases), i per cent; Meriden, .2 
per cent; Hoboken (36 cases), .4 per cent; Yonkers (14 
cases), .1 per cent; New Bedford (174 cases), 1.5 per 
cent; Trenton, only 5 cases reported by one nurse, probably 
15 in all, .1 per cent; Cambridge, .1 per cent; Providence, 
.2 per cent; Jersey City (38 cases excluded), .1 per cent; 
Newark, 3,209 cases excluded and treated by nurses, 13 
per cent (doctors' cases, 162, or .7 per cent) ; Boston, 504 
cases, .6 per cent. 

In Newark, the supposition is that 13 per cent does not 
represent the number of different children affected, but the 
number of exclusions, many children probably having been 
excluded more than once. 

The average percentage seems to be near .4 per cent. 
Any estimate of the actual number of new cases found or 
to be found in any one school year, not counting any child 
twice, is precarious. Probably .4 per cent, or 4 cases in a 
thousand would be near the truth. 

7. SCABIES, ITCH 

The folk term, "slow as the seven years' itch," indicates 
what has been the character of this ailment In the past. 
Now, with sulphur ointment and baths and boiling or bak- 
ing of clothing, the ailment can be killed in a few days. If 
care is not taken to kill off every itch-mite burrowing along 
or resting In the skin, the ailment may, however, last in- 
definitely. In the minds of many physicians the ailment is 
associated with promiscuous sex relations but, as In the case 
with venereal diseases, the innocent are not immune and are 
frequent victims. As with pediculosis, constant scratching 
and marks of scratches on the body or in the web between 
the fingers, are common indices. Many cities now keep 
sulphur ointment for cure and furnish prescriptions, as in 
the cases of vermin and other parasitic ailments. 



COMMUNICABLE AILMENTS 213 

The ailment is even more common than ringworm, and 
very much more distressing to the children afflicted. Some 
of the frequencies are as follows: Only 8 cases given 
separate mention in the first three cities; Winchester (12 
cases excluded), .8 per cent; Montclair, .4 per cent; Mt. 
Vernon, .2 per cent; Hoboken, .2 per cent; Schenectady, .2 
per cent; Waterbury, .1 per cent; Yonkers, .12 per cent; 
New Bedford, i.i per cent; Trenton, .1 per cent; Cam- 
bridge, .2 per cent; Syracuse, .3 per cent; Rochester, .2 per 
cent; Providence (158 cases excluded), .5 per cent; Jersey 
City, .04 per cent excluded; Newark, .8 per cent excluded; 
Boston (648 cases), .8 per cent. 

The average number of cases or exclusions is almost .5 
per cent. The average number of cases among the ele- 
mentary school population in any one year, counting no case 
twice, is probably not far from four in a thousand, and per- 
haps five, say five. The variation is perhaps from about 
2 to ten in a thousand, although, as we have found it, the 
variations among physicians and nurses exceeds, and so 
covers up, the probable variability of cities. 

8. TONSILITIS, QUINSY 

This is generally a rather mild ailment, but may easily 
be confused with the beginnings of several of the infectious 
diseases; so it is treated almost as rigorously as if it were 
a suspected case of diphtheria. The Chicago Board of 
Health rule is: "Cases of tonsilitis must be excluded on 
the clinical evidence alone, and throat cultures made for 
further diagnosis." It is possible for school purposes that 
the ailment may be placed with "sore throat" cases, since 
the treatment is practically the same. Where doctors and 
nurses are sure that the case is tonsilitis and not some other 
form of sore throat, probably infectious, we have a situation 
where it is better to have separate mention of the ailment. 

The ailment is an inflammation of the tonsils which may 
become an abscess. The latter, by breaking while the pa- 
tient is sleeping, may, according to Dr. Ditman (Home 
Hygiene and the Prevention of Disease), cause suffocation. 



214 SCHOOL HEALTH ADMINISTRATION 

The abscess should be opened by a physician. The preven- 
tion is along the line of preventing colds, keeping up the 
resistance, and removing enlarged tonsils. 

A few random frequencies among the elementary school 
populations are: Montclair, 1.3 per cent; Hoboken, .7 
per cent; Yonkers, .15 per cent; New Bedford, .6 per cent; 
Trenton, .2 per cent; Cambridge, .4 per cent; Rochester, 
.15 per cent; Jersey City, ,06 per cent; Newark, 1.4 per 
cent; Boston (1,200 cases), 1.3 per cent. 

The average is .76 per cent. 

The actual number of new cases among the elementary 
school population during any one school year is probably 
not less than one per cent. This is our estimate. Most 
cities simply have not found or have not recorded all cases. 
Less than a half per cent would certainly indicate this. 

We have now completed our survey of minor infectious 
and parasitic ailments. Mulloscum contagiosum is a very 
uncommon ailment belonging to this group, but is not given 
separate mention, only 10 cases having been found in one 
city, Newark. Hookworm is another serious ailments of 
this class that should be included wherever the ailment is 
found, and it seems rather widespread, from reports of 
Rockefeller Institute. 

B. Infections Diseases 

Here we come to those diseases which started medical 
inspection by health departments in cities, in the effort to 
control the causes of death among the young. Beginning 
here, the study of causes and prevention has led to the dis- 
covery of a host of previously unrecognized ailments which 
are only indirectly, if at all, death-dealing. Present studies 
seem to show that the school is a very slight factor in the 
spread of infectious ailments, contrary to the long accepted 
opinion; and, moreover, it is surprising how small a per- 
centage of the actual cases are found in the schools before 
they are found and isolated by the parents or family phy- 
sicians. It must be remembered in this list that many of 
the cases reported or excluded are only suspected cases, and 



COMMUNICABLE AILMENTS 215 

that a further large number of children have been excluded 
because they lived in the same family or same house as those 
ill. An interesting and needed study is the comparison of 
the number of cases reported by boards of health and the 
numbers found which actually prove to be cases by the 
school medical service. Another dangerous factor is the 
disease carrier, a child healthy but carrying and distributing 
deadly bacilli. 

We should expect that those inspectors and nurses under 
boards of health would make a better showing in the field 
we have now entered than the board of education medical 
workers, for some of them have done little else than look 
out for and report suspected infectious cases. Let us see. 

In the table, excluded cases are marked X, merely sus- 
pected cases where so reported are marked with a ?. 

I. CHICKEN POX, VARICELLA 

Summit school health officers found no cases of in- 
fectious or suspected infectious diseases In the schools dur- 
ing the year, so far as I could learn from the superintend- 
ent and physician. Many cases actually occurred, however, 
and the schools learned of them through reports of the 
Board of Health. In the writer's opinion, infectious dis- 
eases are a most important part of school health records 
whether cases are found in the schools or not. The number 
of cases of these ailments and the number of deaths of chil- 
dren of school age in each city are given in the tables. 

Eight children were recorded as having had treatment 
in Norwood, .7 per cent of the elementary school children; 
Winchester, 1.3 per cent; West Orange, .7 per cent ex- 
cluded; Montclair, i per cent; Meriden, .2 per cent; Mt. 
Vernon, only one case excluded; Newton, .4 per cent prob- 
ably excluded; Hoboken, .3 per cent; Trenton, with a large 
medical force, comparatively, and over 10,000 examinations 
and 8,000 special inspections, and 3,400 inspections by 
nurses, found only one case of chicken pox in the schools; 
Cambridge, 1.5 per cent; no cases reported by either Lowell 
or New Haven, the latter under the Board of Health; 



2i6 SCHOOL HEALTH ADMINISTRATION 

Syracuse, .2 per cent; Jersey City, .06 per cent; Newark, .9 
per cent (better reduced to .5 per cent by using not the 
number examined but the entire elementary school enroll- 
ment, perhaps, as explained elsewhere) ; Boston (based on 
elementary school enrollment, not on number of inspections 
of special cases, counting 500 cases found by both doctors 
and nurses), .5 per cent. Several cities have been left out, 
as usual, because the cases found were so few. They are 
not representative. 

The average frequency of suspected, or actual, cases 
found in the schools according to these summaries is .6 per 
cent. 

This, perhaps, is near the actual number of cases. We 
cannot tell. Many of the cases found are children who 
have returned, in the opinion of doctor or nurses, too early. 

2. DIPHTHERIA 

This dread disease is well known, but science is gaining 
control over it. The most remarkable decreases in fatalities 
from any disease are shown for this ailment and typhoid. 
The 19 1 1 Board of Health report for Boston (pages 
182-3) shows that in 1878 and many years later the ratio 
of deaths to number of cases was nearly half, and not as 
low as one out of three dying until 1889. But since 1907 
the percentages have ranged around 6 per cent, or about 
one out of fifteen or sixteen cases ill. 

Still there were 2,081 deaths from this disease in 19 10, 
so it is yet a very real terror. 

Fewer cases or suspected cases of this ailment were 
found than in the case of chicken pox, 17 cities giving 
practically no mention of it. The most interesting struggle 
with infectious diseases in any of the cities during the years 
studied, was probably that in South Manchester. There 
were three epidemics; one of diphtheria, one of scarlet 
fever, and another of measles. The school physician was 
paid an extra hundred dollars to inspect almost all the 
children in the school system once a week for six weeks. 
(See 19 1 1 report.) The health department and the school 



COMMUNICABLE AILMENTS 217 

officials did everything possible but the epidemics continued 
almost as if nothing were being done. Here we have a 
very severe test of school medical inspection. 

One thousand six hundred and ninety-three days were 
lost from school by 65 pupils ill with diphtheria, and 1,666 
by 73 others quarantined because of exposure, a total of 
3,359 days (number excluded, 138). For scarlet fever 
other pupils exposed, 2,728 days, a total of 4,731 days. 
there were lost by 75 children ill, 2,003 days, and for 71 
Diphtheria occurred in 67 families and scarlet fever in 65. 

In the Inspections, 585 cultures were taken, of which 
143 were reported positive. Some carriers were found. 
These tend to show that the number of cases might have 
been greater had there not been the extraordinary inspec- 
tion. On the whole, however, it shows the probable limita- 
tions of school inspection. The schools were not closed 
during the epidemics, as would be the cases in many cities 
so stricken. Three children died of diphtheria. At the end 
of the year it was found that the promoted pupils had lost 
on an average 32 of the 186 school days, while the non- 
promoted pupils lost 52 days, a difference of six and ten 
weeks. How much was due to the absence, or from the 
absence for any one cause was not worked out. 

The President of the Board of Education, also a member 
of the State Board of Education of Connecticut, estimated 
the cost to the schools of the diphtheria and scarlet fever 
cases at $2,500; these and lesser infectious diseases like 
measles, at $5,000, all as "ineffective expenditures." And 
"we cannot estimate the cost to individuals, but assuming 
that the serious diseases cost the parents even so low an 
average as $25.00 each, and the milder ones $10.00, the 
direct burden would be In excess of $5,000. If to this were 
added the expenses of the health officer, and wages lost by 
quarantines, we are certainly within the truth in affirming 
that the sum of the expenses of the town and individuals 
incidental to contagious diseases was not less than $12,000, 
and may easily have been $15,000." 



2i8 SCHOOL HEALTH ADMINISTRATION 

The Superintendent's reasoning on the cost of these ail- 
ments is shown in the following paragraph: 

"The total time lost by children who were excluded for 
the two diseases was 8,090 days. This was equivalent to 44 
school years for one pupil or 44 children lost one year's 
schooling. Last year it cost $35.28 to promote one pupil 
one grade. The 44 years of time lost had a money equiva- 
lent of $1,552. If to this sum should be added the time 
lost by the children where parents kept them from school 
through fear of contagion, and those who were absent sev- 
eral days awaiting the report of cultures, it is probable that 
the sum would be about $2,500 in time lost by children 
absent from school. To this must be added the time con- 
sumed by teachers in attempts to bring the absent pupils 
back to grade which always contains an element of loss to 
the pupil who attends regularly and who loses some portion 
of the teacher's time expended upon the irregular pupil. 
. . . There were three deaths from diphtheria, a loss to 
parents which cannot be computed in money and in which 
they have the sympathy of the whole community." 

We give a page or so to the Manchester experiment to 
show the loss of this and other such ailments to a com- 
munity; to indicate the limitations in even a small city on 
health control; and to point out a statistical fallacy which 
has become very frequent in school reports since Ayres' 
publication of such fiscal studies, also fallacious. 

On the second point, Mr. Cheney urges a contagious 
hospital for the town, and to the writer suggested the very 
great need of state-pay for laborers who were quarantined 
in order that effective quarantine may be obtained. "The 
infectious ailments spread in the mills, principally, and on 
the streets, and not so much in the schools," he said. 

This points out one of the most important problems of 
medical Inspection — that of preventing the spread of infec- 
tious diseases outside of the schools, on the streets and in 
the backyards where children play, and also in the mills 
and stores where children, youths and adults work. It is a 
nice problem for real investigation. 



COMMUNICABLE AILMENTS 219 

The fiscal fallacy Is in computing the cost of retardation 
and school absence without any regard to the economic laws 
of diminishing expense. 

Illness, exclusion, and quarantine absence can be rela- 
tively accurately computed; and, with great care, some 
notion of the effect these absences have upon retardation 
can be ascertained; the costs to parents and other such items 
can be worked out; but the loss to a school system in money 
from either absence or retardation cannot easily be dis- 
covered, and has not yet been done. School rooms are not 
very often used to their full capacity all the time. The 
pupils of any building who fail in any one year, can usually 
be accommodated in the same building. Promotions are 
made somewhat upon the basis of the number of vacant 
seats to be in the room above. Pupils in the upper grades 
of crowded districts are frequently sent to other schools 
where there are uncrowded class rooms. A number of chil- 
dren fail at each annual promotion, and yet no new teachers 
are employed for the building, no extra heat or janitor 
service is used, very little extra is spent for supplies. The 
cost of retardation or of absence almost disappears in the 
situation. How much the school system is increased by the 
damning up process of retardation, i. e., how many more 
teachers and rooms are necessary, has not yet been dis- 
covered. 

All the statistical studies of this kind, on the Ayres' plan, 
go on the assumption that the situation is the same as If all 
the children failing of promotion each year were put off 
into separate buildings from the main system. Thus Cleve- 
land reports (1911 Report) an appalling loss of school 
money due to retardation. The method Is that of multiply- 
ing each year of retardation by the per capita cost of the 
schools. Such figures may have some pragmatic value in 
obtaining public support, but they are undoubtedly very far 
from the truth. The law of diminishing expense would 
show that the "wasted expenditures" were probably quite 
small. So that we must be very careful In computing the 



220 SCHOOL HEALTH ADMINISTRATION 

money cost of illness absence. The most important losses 
here are other than financial. 

FREQUENCY OF DIPHTHERIA 

South Manchester, 4.2 per cent; none of the other cities 
have more than one to four cases until we come to New 
Haven with 164 cases, .7 per cent; next three cities with no 
more than four cases; Jersey City, .1 per cent; Newark, 
.1 per cent; Boston (nurses reporting 752 cases), .8 per 
cent of total elementary enrollment. The total number of 
cases in the city of Boston in 19 10 was 2,453. 

The average of these cases would be relatively insig- 
nificant. The general tendency can hardly be told from 
these figures. The average is, however, .1 per cent. The 
number of cases, or suspected cases, is very small compared 
with the total number of cases among school children. 

In New Bedford, for example, in the year 19 10 no sus- 
pected cases, even, of diphtheria were found in the schools 
by the medical inspectors, but there were reported to the 
other division of the Board of Health 96 cases with 24 
deaths. The inspectors did find 5 suspected cases of measles 
or children who had returned too early; but there were re- 
ported to the contagious disease division 697 cases and three 
deaths. Likewise the school inspectors found 7 cases or sus- 
pected cases of scarlet fever in the schools, while there were 
reported to the board of health from the homes 246 cases 
and 5 deaths. All of these persons with the ailment prob- 
ably were not school children and ages are not given by ail- 
ments, but a very large proportion undoubtedly were. We 
leave it with an estimate of 12 cases in a thousand to be 
found in a school. All cases among school children should 
however be recorded on the school card. 

3. MEASLES 

This ailment is very much better reported. The death 
rate, too, is very much lower; 1,112 cases are reported by 
doctors and 214 cases by nurses in all the cities, a percentage 
of the entire elementary school population, counting 1,200 



COMMUNICABLE AILMENTS 221 

cases of all the cities, amounting to about .3 per cent. The 
variations are from zero in seven cities to 5.6 per cent in 
Meriden. The latter included suspected cases of German 

measles. 

The probable frequency of cases actually present in a 
school year in an average city is perhaps around .4 P^r cent. 

Any study of reports shows consternation and surprise 
on the part of superintendents that medical inspection and 
examination has done so little in controlling this ailment. It 
simply shows that in this respect as in many others the 
school must reach out into the home and other phases of 
life in order best to serve the children. 

Another point is, too, that very little is yet known 
regarding children's diseases. Medical schools do not 
emphasize the subject and most medical research has been 
in other fields. 

4. MUMPS 

Of this ailment only 671 cases or suspected cases are 
reported by physicians and 1,388 cases by nurses, the Boston 
nurses contributing nearly all of these, 1,344 cases. (Bos- 
ton then had 35 nurses and now 46.) The ratio to the 
entire elementary school population in all cities is (counting 
1,400 cases) .3 per cent plus, a little more than for diph- 
theria. 

No city stands out here, except perhaps the nurses' cases 
in Boston, 1.5 per cent. How many of these were duplicates 
we know not, since the Boston report gives only bare sum- 
maries. Some of the other frequencies are: Newark, .2 
per cent plus; Rochester, .08 per cent; Yonkers, .8 per cent; 
Hoboken, .08 per cent; Meriden, .3 per cent; Montclair 
(nurse, 22 cases), .7 per cent; West Orange, .3 per cent. 

The average is about .4 per cent, about 4 cases among a 
thousand pupils in a school year. 

5. SCARLET FEVER 

The total number of cases in all cities reported by school 
doctors is 832 and by nurses 676, nearly all of which were 



222 SCHOOL HEALTH ADMINISTRATION 

furnished by the Boston nurses. Probably the only places 
where cases were duplicated by the nurses' reports are 
Syracuse, Providence and Boston. Subtracting a hundred 
cases for this and we have left at least 1,408 cases among 
an elementary school enrollment of more than 414,000, 
making a frequency of .3 per cent plus. Some of the fre- 
quencies are: South Manchester, nearly 5 per cent; Win- 
chester, I per cent; New Haven, 2 per cent; Jersey City, 
.2 per cent; Newark, .05 per cent on total elementary enroll- 
ment; Boston, .6 per cent. 

The average for these higher cities is over i per cent. 
We leave the frequency estimate at .4 per cent as a mini- 
mum ratio. 

6. TRACHOMA, GRANULATED EYE-LIDS 

Of this terrible ailment, so guarded against at our ports 
of entry for immigrants, there were reported by the in- 
spectors 281 cases in all cities, and 104 cases by the nurses. 
Subtracting 75 cases from the combined sum we have left 
probably 310 cases, about .08 per cent, not far from one 
case in a thousand. 

Summit had .2 per cent nearly; Mt. Vernon, over .1 per 
cent; Yonkers (70 cases), .5 per cent; New Bedford, .1 
per cent plus; Cambridge, .1 per cent; Jersey City, .07 per 
cent; Newark (100 cases treated), nearly .2 per cent. 

We leave the estimate at .1 per cent, or one case in a 
thousand. Cities reporting fewer cases than this conserva- 
tive estimate very probably haven't found the cases. The 
cleanest little cities have cases of the ailment. Yonkers, as 
with almost all the ailments, shows very high percentages, 
abnormally so in some cases. The indications are that per- 
haps no city more needs an enlarged force of doctors and 
nurses. Those in authority have said, however, that Yonkers 
is such a nice town that much medical service in the schools 
is not needed. The number and character of the ailments 
point in the other direction. 

7. PULMONARY TUBERCULOSIS, CONSUMPTION, PHTHISIS 

This ailment is surprisingly uncommon among school 



COMMUNICABLE AILMENTS 223 

children when the large number of adults having it are 
taken into consideration. A number of the cities had, and 
more now have, open air schools for anemic children and 
those with tubercular symptoms or tendencies. Probably 
the most complete reports of such work occur in the South 
Manchester, Cambridge and Newark reports. The von 
Pirquet skin test with tuberculin is used in several places 
to assist the doctors in diagnosis. There was much hope 
that the Friedman antitoxin would prove a radical remedy 
and make possible the rapid cure of all such cases. The 
open air schools would still have their place, however, for 
weak, anemic, poorly nourished children can best be fed and 
cared for in such a school. The great need is, of course, 
more fresh air and outdoor life for all schools. What is 
good for a few afflicted, is good, and can be provided, for 
all, so far as air is considered. Open window schools are 
growing in numbers. A lowering of the temperature of 
heating coils In the fan rooms, so that air will not be baked 
and made over-sultry, is also very much to be desired, and 
will give more nearly outside conditions. Moistening the 
slightly heated (not much over 60 degree) air, is also neces- 
sary in forced systems to complete more nearly the supply- 
ing of the best outside conditions. 

Probably 420 cases of suspected cases of pulmonj>ry 
tuberculosis were found in the 25 cities, a percentage of 
.1 per cent. Montclair had about 44 children In her open 
air school, but the number responding to the tuberculin test 
is not given. It Is very difficult to tell, and It is not perhaps 
important to tell exactly, how many children in the schools 
actually have pulmonary tuberculosis. It is not very hard 
for the experienced physician or nurse to pick out those chil- 
dren who run a very great chance of getting it and dying 
from it before they are thirty years of age. If conditions 
can be so modified that no actual cases may be found, a very 
great deal In the essential work of prevention may be done. 
Here is one of the principal places where the nurse's work 
for home hygiene counts In the best way. School feeding 
Is very Important; good home feeding is better If It can 



224 SCHOOL HEALTH ADMINISTRATION 

be secured. Home ventilation, cleanliness^ a chance to 
play out-of-doors, comfortable clothes, no over-work or 
home study, decent treatment, plain nourishing food, and 
the remedying of physical defects and ailments : all these 
come within the province of the modern school nurse in the 
service of the coming generation. 

8. TUBERCULOSIS OF BONES, JOINTS, AND OTHER PARTS OF 

THE BODY 

Enlarged glands, when they are found tubercular, may 
be placed in this group. Pott's disease is a common name 
for tuberculosis of the spine, the ailment which causes the 
hunch-back. Fortunately this form of tuberculosis is very 
infrequent, only about 50 cases being reported in all the 
cities, about .01 per cent. Cambridge reports 27 cases, 
nearly .2 per cent; and Trenton has a showing of 18 cases, 
or over .1 per cent. If all the cases existing were actually 
found the percentage would not be far from .1 per cent in 
all cities. We leave it as about that sum. 

9. WHOOPING COUGH, PERTUSSIS 

This is quite a common ailment and frequently the cause 
of death. It is one of the greater /iw^-killers of all school 
ailments, the period of exclusion being so long. There was 
a combined number of 693 cases reported in all cities of 
which probably 133 were duplicates, leaving 560 cases, a 
frequency of over .1 per cent (.13 per cent). Nine cities 
do not mention the ailment, five boards of education and 
four boards of health. It would seem that the latter would 
give especial attention to this infectious ailment. Some of 
the frequencies are: Winchester, .6 per cent; Montclair, 
.7 per cent; Meriden, .5 per cent; Hoboken, .2 per cent; 
Providence, .07 per cent; Jersey City, .07 per cent; New- 
ark, .14 per cent; Boston, .3 per cent. 

The higher percentages average ,3 per cent. 

The probable number of children in the schools during 
the school years is perhaps above even this figure. But we 



COMMUNICABLE AILMENTS 225 

leave the probable percentage at .2 per cent of the ele- 
mentary school children, or two in a thousand. 

SUMMARY OF ALL 54 AILMENTS 

We have now come to the end of a long, hard journey 
through the ills of childhood. We have tried to look facts 
in the face and see what these ailments are, how frequent 
they are, how various cities do their duty by the ailing chil- 
dren, and we have also endeavored to develop tentative 
standard percentages which may be the start toward coefi- 
cients which will prophesy as accurately as insurance tables 
about how many of these various ailments we may expect 
in a school population, and how far below the normal vari- 
ous cities pass. 

The various percentages are collected on a later page. 
The deaths from these ailments will also be given, as well 
as a summary of the exclusions. We do not enter into the 
laborious task of testing each city by these percentage stand- 
ards to determine its relative standing. If anyone cares to 
do this the figures are given for it. Rigorous comparisons 
are perhaps not now needed so much as ideals, norms, and 
efficient methods of administration. 



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CHAPTER NINE 

SPECIAL PHASES OF MEDICAL INSPECTION IN 
THESE CITIES 

In preceding chapters we have attempted to describe 
and evaluate the general administration of medical inspec- 
tion, the work done, and the ailments or disorders found 
among the school children of these cities, especially those 
of the elementary schools. In this chapter it becomes our 
problem to set forth briefly some of the good features of 
these various medical inspection systems which are some- 
what in the nature of departures from the simple inspection 
and examinations by doctors and nurses. Here we shall 
abandon the method of analyzing the data strictly by cities, 
and treat the problem on the basis of topics or phases em- 
phasized. Some of the most important of these phases are : 
the methods of getting treatments and the starts toward 
school clinics, the various preventive methods carried on 
by this department, the examinations of children for work 
certificates, and the various more or less scientific investiga- 
tions of the work carried on by the departments themselves 
or by other school officials. 

I. TREATMENTS AND SCHOOL CLINICS 

The special methods of procuring treatments adopted 
by medical inspection systems in these cities are both private 
and public. The schools carry on and pay for certain work, 
and also encourage or permit a good deal, but not enough, 
voluntary assistance by private organizations and individ- 
uals. The ideal towards which the schools seem every- 
where to be directed more or less vaguely Is that of a first 
class school clinic accessible to every child and free to every 
child who wishes, or whose parents wish him to take advan- 
tage of free diagnosis and treatment, with the further pro- 

228 



PHASES OF MEDICAL INSPECTION 229 

vision that every child hi a school system must either pri- 
vately or publicly be placed in good physical condition, and 
that there can be no escape from this provision. Com- 
pulsory education seems absolutely to involve com- 
pulsory health and the most economical way for a com- 
munity to provide adequate diagnosis, prevention and con- 
tinued or immediate treatment is through the instrumentality 
of the public schools. Why the schools have gone so long 
with almost utter disregard for the health and normal 
physical development of their compulsory charges, argues 
"a certain blindness of human nature" in the teaching 
profession. This blindness, of course, which is almost a 
physical defect, comes naturally out of the excessive isola- 
tion of our public schools and teachers from the real life 
and needs of our people. When we take the attitude that 
the problems of the people and the nation set the problems 
for the public schools, then we shall have a sensitive adapta- 
tion of our educational systems to the real life of the times 
and the children to be adapted. 

Some of the essentials of adequate school clinics seem 
to be the following: 

1. Convenience to the pupils, perhaps for the most 

part and for the ordinary cases, in every school. 

2. Several divisions in the charge of specialists with 

nurse assistants. 

3. These divisions, for a beginning, may be: 

a. Dental, in charge of dentists. They will ex- 
amine the cases sent in by nurses and doctors 
and give such treatment as is necessary, and 
such advice for dental care as seems desir- 
able, requesting parents, nurse, and teacher 
to see that they are followed. Small charges 
may be made where they seem desirable, 
though this seems as unnecessary as volun- 
tary payment for the free text-books and 
other supplies furnished by the schools. It 
is as much the advantage of the state to have 



230 SCHOOL HEALTH ADMINISTRATION 

children in good health as It Is to have them 
get a certain amount of schooling. And the 
retarding effect of the various ailments may 
well cause such waste of time and money 
as to pay for adequate clinical provisions. 

b. Surgical, in charge of surgeons. This division 

will, with parents present as much as pos- 
sible (and parents will come out to clinics 
when they will not come to mere examina- 
tions), remove such adenoid and tonsillar 
tissues, and make such other dressings and 
simple surgical treatments as good judgment 
provides. Cases of strabismus (cross-eye) 
and defects requiring operative treatment, 
may well be handled by this division. 

c. Medical, In charge of regular physicians. This 

division will devote Itself to the diagnosis of 
referred cases of many ailments not falling 
to other divisions and the giving of skilled 
treatments. With scalp ringworm cases 
needing X-ray treatment, or with discharging 
ears, favus cases, or any other of a host of 
ailments which cannot adequately be handled 
by the nurses, we have cases for this division 
of the clinic. The Dunfermline (Scotland) 
clinic has such divisions and the medical di- 
vision reports a very large amount of work 
for a small city of about thirty thousand 
population. 

d. Ocular, for eyes and vision, in charge of 

oculists. This division will handle both the 
treatment of eye ailments and make careful 
vision tests of referred cases, furnishing 
either prescriptions alone or prescriptions 
with the proper glasses. Providence has al- 
ready entered this field and every city must 
undoubtedly follow. 



PHASES OF MEDICAL INSPECTION 231 

e. Medical gymnastics division, if this is not cor- 

related with the department of physical edu- 
cation. 

f. Psychological division, for testing backward 

children.* 

Practically no school system of this country has yet a 
clinic so well worked out and so paternal as this, although 
there are a number of approximations to it, and we can 
see scattered over the country its various elements. We 
shall begin our further study of the cities with the various 
means of: 

A. Public School Treatments. 

The work of the nurses consists of assisting the doctors 
at examinations and making vision and hearing tests. In- 
specting the children, visiting the homes to help get pre- 
ventive measures and treatments, taking the children to free 
dispensaries or to private physicians, and, finally, in treating 
the children themselves. 

Physicians are, for the most part, prohibited from mak- 
ing treatments, and the nurses' work In the field of treat- 
ment ranges In these cities from almost zero up to the large 
amount of work done In Newark and a few other cities. In 
some cities, as at New Haven, all the medical supplies and 
Instruments were carried in the nurse's bag, and consisted 
of: 

An ear syringe, a sponge, some bandages, two small 
basins, combs for pediculosis, bichloride tablets, olive oil, 
zinc ointment, sulphur ointment, scissors, tongue depressors, 
and a graduated glass. 

From such small beginnings and less, the work ranges 
upward to finely equipped medical inspection rooms, or 
school clinics, in many or most of the school buildings and 
with a large list of medical supplies kept at the central sup- 
ply department and furnished to schools on the requisitions 
of principals along with other school supplies. For Boston, 



*Dr. Cornell suggests other divisions in his book. 



232 SCHOOL HEALTH ADMINISTRATION 

the requirements for a medical inspection or "nurse's room" 
are given in the report of the School-house Commission, 
and the writer got further details at first hand. The plans 
for the room and the equipment are much the same as those 
already given in a former chapter for Summit. The same 
room could be fitted up for the use of one or more of the 
above-mentioned clinical divisions, of course, if they could 
work at different times of the week. The medical inspec- 
tion cabinet and desk combined in use at Boston is the best 
seen, but a better one was found by the writer in the Depart- 
ment of School Buildings in the City of New York, The 
latter is a desk cabinet, with two doors below, and drawers 
and pigeon holes above which are shut up and covered over 
by a glass covered door which lets down by hinges at the 
bottom and makes a writing desk. The top of the cabinet 
is covered with slate to keep it, like the top of the desk, 
from being injured by chemicals or medicines. 

Most cities have in one to all of the buildings emer- 
gency medical cabinets, made up by the nurses or doctors, 
or sold complete by various medical supply houses. A very 
small one found in New Bedford consisted of a tin box 
ten inches square and about three inches deep and containing 
the following: 

An envelope containing scissors, safety pins, and pincers, 
a handbook of first aid to the injured, absorbent cotton, 
gauze, a tourniquet, a package of bandages, six bandage 
rolls, a box of adhesive plaster, and camphenol ointment. 

Such emergency outfits are, of course, unnecessary where 
the same materials are kept in an adequate medical inspec- 
tion cabinet in each medical inspection room in each school. 

The list of instruments furnished physicians and nurses 
vary very much. In Providence, the school dentist carries 
with him seventy-five teeth mirrors, so two rooms of chil- 
dren can be examined at a visit without any disinfection of 
mirrors. Hoboken has perhaps the longest list of medical 
tools furnished each school, and the entire list of medical 
supplies may here prove interesting and suggestive: 



PHASES OF MEDICAL INSPECTION 233 



1. Jones' platform scale with 

height standard attached. 

2. Ear speculum. 

3. Nasal speculum. 

4. Head mirror. 

5. Teeth mirror. 

6. Tuning fork. 

7. Stop-watch, one for each physi- 

cian. 



8. Spirit lamp. 

9. Tape measures. 

10. Enamel basins. 

11. Tongue depressors. 

12. Applicators. 

13. Absorbent cotton. 

14. Gauze. 

15. Gauze bandages. 
i6. Lysol. 



Among the lists found in other cities the following fur- 
ther items were found: 

Water heaters. 

Paper and cloth towels. 

Aromatic spirits of ammonia. 

Collodian. 



Rubber gloves. 

Medicine droppers. 

Forceps. 

Uniforms for nurses. 

Carrying bags for nurses. 

Clinical and other thermometers. 

Hair brushes. 

Bath caps. 

Tooth picks. 

Graduate glasses. 

Surgeon's needles. 

Bandage jars. 

Adhesive plaster. 

Mercury bichloride tablets. 

Peroxide of hydrogen. 

Disinfectants, sulphur naphol, etc 

Green soap. 

Boric acid. 

Jamaica ginger. 

Ammoniated mercury. 

Creolin. 

Marigold ointment. 

Witch hazel. 

Chamois skin. 

Tongue depressor handles. 

Vaccination shields. 

Enameled table with glass shelves 

Couches. 

Medical cabinet. 

Chairs. 

Floor mats, rugs, and pillows 



Larkspur, for pediculosis. 

Kerosene, for pediculosis. 

Creasol, for pediculosis. 

Sulphur ointment, for scabies. 

White precipitate ointment. 

Iodine. 

Sweet oil. 

Wood alcohol. 

Toothache drops. 

Oil of cloves. 

Argyrol. 

Comp. stearate of zinc. 

Vaselene. 

Comphenol. 

Adreniline. 

Powdered chalk. 

Glycerine. 

Boric acid ointment. 

Vinegar, for pediculosis nits. 

Vitagen. 

Alcohol. 

Muslin. 

Vision test charts. 

Tooth brushes. 

Eye glasses, spectacles. 

Combs. 

Sterilizing outfits. 



A study of the cost of all these items was made in each 
city, and comparisons made. Cities that have tried to get 
along by buying an article or two of local druggists when- 
ever they were needed have wasted a good deal of money. 
Twenty-five cent hair brushes, for example, have been sold 



234 SCHOOL HEALTH ADMINISTRATION 

for $1.50 to the unsuspecting. Changes in certain cities 
have since been made along these hnes in the direction of 
having budgets made up each summer for the following 
year, and then the lists offered for bidders from anywhere. 
The big supply houses have come into the market and sold 
all the supplies very reasonably. This is desirable economy 
in line with other business improvements. 

A list of the medical inspection supplies furnished in 
quantities at Newark is here appended: 

FOR MEDICAL INSPECTORS 

Absorbent cotton, ^ pound packages, J. & J. Red Cross. 

Alcohol, grain — 95 per cent. 

Tongue depressors, in packages of 100. 

Bandages — 2-inch by 10 yards, J. & J. Linton gauze. 

Bichloride of mercury tablets — yj^ gr. (lOO tablets in a bottle). 

Tincture of green soap, 6-ounce bottle. 

Glass jar, 2-quart. 

Eleven different forms, envelopes, prescription pads, etc. 

FOR SCHOOL NURSES 

Absorbent cotton, ^-pound packages, J. & J. Red Cross. 

Bandages, i-inch by 10 yards, J. & J. Linton gauze. 

Bandages, 2-inch by 10 yards, J. & J. Linton gauze. 

Adhesive plaster, 2-inch by 10 yards, J. & J. "Z. O." 

Alcohol, grain — 95 per cent. 

Plain gauze, I yard long, i yard wide, J. & J. Red Cross. 

Argyrol, 5 per cent. 

Bichloride tablets, 7J4 grains. 

Flexible coUodian. 

Iodine, tincture. 

Lysol. 

Sulphur ointment. 

Sweet oil. 

Stearate of zinc (powder, in boxes). 

White precipitate. 

Zinc ointment. 

Bottles, 4-ounce, with corks. 

Ciliary forceps, No. 1628. 

Clinical thermometer. 

Ointment jars, 4-ounce. 

Tooth picks. 

Three blank forms. 

FOR PRINCIPALS 

Cotton, bandages, adhesive plaster, aromatic spirits of ammonia, 
and three blank forms, reports on medical inspection. 



PHASES OF MEDICAL INSPECTION 235 

FOR SANITARY INSPECTOR 

Formaldehyde. 

Kerosene oil. 

Alcohol, wood. 

Cotton, American Beauty. 

Two blank forms, one a report of sanitary inspection of schools 
and of disinfection, and the other a report of visits to the homes of 
quarantined pupils. 

FOR SUPERVISOR OF MEDICAL INSPECTION 

Form 93, a permit for children to attend school. 

Here we have about the best that has been worked out 
in the way of medical inspection supplies, and this list will 
probably soon be added to if the efforts for a first-class 
school clinic are successful. 

PRESCRIPTIONS 

It has been found necessary and desirable to print pre- 
scriptions in the various languages of the city population for 
a rapidly increasing list of school ailments. Some of these 
are at present for: pediculosis (lice), ringworm, impetigo, 
scabies, caring for the teeth (tooth powders), and home 
and school advice which amounts to prescriptions for a 
great variety of other ailments of a simple character. We 
have not begun to discover what a wide field of health edu- 
cation of adults exists in the form of well written and illus- 
trated pamphlets, not to mention lectures, home-visits, etc. 
A very valuable book for home treatment and prevention 
of disease has been written by Professor N. E. Ditman, 
M, D., of Columbia University, entitled "'Home Hygiene 
and Prevention of Disease" (Dufl^eld & Co.). It is in the 
form of a small one-volume cyclopedia, beginning with 
"Abscess" and ending with "Wry-neck," and comprising 
very practical and scientific advice on practically every phase 
of health in the home. I wish I had the power to place 
it in the hands of every parent, intelligent enough to read 
the newspapers, in America. The book, of course, shows 
the limitations of home treatment and shows also where the 
expert skill of medical men is necessary; but it does clear 
away a great deal of the superstition, inscrutability, and 



236 SCHOOL HEALTH ADMINISTRATION 

awesomeness of ill health, and shows plainly and simply 
each individual's responsibility for prevention and cure. 
Such knowledge is, of course, essential matter for our high 
school courses in hygiene, but the pupils there do not get 
such knowledge or acquaintanceship with such book-tools, 
because they are so busy cramming comparatively useless 
information. 

HEALTH LECTURES 

A new departure is the wide range of simple health 
lectures being given in many cities. Newark has four or 
five hundred a year, given by specialists or persons well 
qualified to speak, on a great variety of health topics. The 
nurses and doctors also give a great number of health talks 
to the children and teachers of the schools. Stereopticons, 
tuberculosis exhibits, dental exhibits, budget exhibits, and 
moving pictures all are, or can, be enlisted to bring to the 
people the health knowledge which is essential to the 
saving of many of their lives or, at least, conserving and 
developing their efficiency in their daily work. Denison's 
"Helping School Children" (Harper's) is filled with sug- 
gestions for promoting the health of the school children and 
their friends and relatives. 

SCHOOL OCULISTS 

We have mentioned the school oculists at Providence, 
and the splendid work they are doing for getting scientific 
diagnoses and accurate prescriptions and glasses for school 
children. The school ocuHst is bound to come. These two 
oculists at Providence give "two afternoons a week at the 
Fourth Ward Room for examining eyes," for which they 
receive an annual salary of $300. Several more are needed 
more afternoons a week. 

SCHOOL NEUROLOGISTS 

Providence has also the only school neurologist in this 
group of cities, or had at the time of this study, 1910-11. 
Neurologists or psychologists for testing mental defective- 



PHASES OF MEDICAL INSPECTION 237 

ness and helping with the education of backward and feeble- 
minded children are, however, to be found in a number of 
cities (e. g., Cleveland and Los Angeles) in the United 
States. Their work could hardly be called treatment per- 
haps, but they are naturally mentioned in this place. 

B. Treatments by Private Organizations 

The great field for private health assistance to the 
schools has been, it seems, in the field of school dentistry.* 
We find groups or associations of dentists in many cities 
volunteering their services. 

The following cities of the twenty-five had more or less 
of such voluntary work during the years of this study: 
Summit, Norwood, Winchester, Montclair, Meriden, Wa- 
terbury, New Bedford, Trenton, Cambridge, Lowell, 
Rochester, Newark, and Boston. 

In Winchester, the dentists have a schedule of half days 
on which they will work and give their services, with nom- 
inal charge of twenty-five cents a case. In Cambridge and 
Waterbury the school department has purchased chairs at, 
or less than, $300 each, which are taken from school to 
school as needed. In New Bedford, the Health Depart- 
ment spent $600 for a chair and other equipment for a 
dental room, all of which was placed at the disposal of the 
volunteer dentists. In Trenton, a very finely equipped 
dental suite of rooms is furnished by the city in the new 
city hall. Such volunteer work goes along very well for a 
time, but it almost invariably breaks down unless a city 
responds soon and takes the new institution over. No city 
at this late day really needs to be convinced by volunteer 
demonstration of the necessity of such clinics or divisions 
of clinics. The experience of cities the world over is at the 
disposal of any who wish to meet the vital health problems 
of the people. 

In Boston, as related, the new Forsythe Dental Dis- 
pensary, left as a private bequest, is almost extensive enough 
to handle the dental problem of all the children of Boston 



*Providence alone, also, had a school dentist emploj^ed b)^ the city. 



238 SCHOOL HEALTH ADMINISTRATION 

up to the age of sixteen years. It is not thought that existing 
dentists will suffer by such an arrangement. Rather they 
will gain through an adult population educated in the 
realization of the value of good dental services.* 

Other voluntary forms of health and medical service to 
children are : the provision of clothing brought in by the 
children and distributed by the nurses, the provision of 
outings on private bequests, as at Brockton, the provision 
of free eye-glasses, the various hospital and dispensary 
forms of treatment offered and given so freely and gen- 
erously to all that the nurses bring or send, the feeding of 
the undernourished, the open-air schools, and a great host 
of other ways almost too numerous to mention but springing 
into being wherever the school officials or the public or both 
together are genuinely sensitive to the health needs of the 
actual children in the public schools and homes. 

The administrative solution of the problem of treatment 
is to organize it, get it into the hands of skilled and perma- 
nent workers, and to make the private work become public 
policy as soon as its value is demonstrated, thus leaving new 
fields open for private initiative. School superintendents 
frequently do not see very clearly the health needs or are so 
engrossed with other matters that they have no time for 
health essentials. This and a number of difficulties has led 
the writer to advocate a thorough integration of all health 
agencies in a school system, in one department of hygiene, 
and under one physician, physical-educator, or educational 
hygienist, who will be responsible for the health and normal 
physical development of the school children. The divisions 
of such a department may well be, as before stated, and 
first so listed by Dr. Woods, I believe: Medical Inspection, 
School Sanitation, the Teaching of Hygiene, Physical Edu- 
cation, and the Hygiene of Teaching. The salary for such 
a man will be near $3,000, not less; but ways can easily be 
devised in many cities for acquiring him with little extra 



*Such dental work in public schools will be found well treated in 
Gulick and Ayres' Medical Inspection of Schools, 1913 edition, and 
Cornell's Health and Medical Inspection of School Children. 



PHASES OF MEDICAL INSPECTION 239 

expense, and several small cities can go together to get one 
man as they now do in New England for superintendents. 
In the country, there can well be a county, or township 
Director of Hygiene who can examine children, direct 
nurses and assist physicians, and promote all health phases 
which are now so terribly neglected in many or most country 
schools.* 

II. PREVENTION IN MEDICAL INSPECTION 

The principal preventive work of such systems is, quite 
largely, that of education, finding incipient cases of all kinds, 
the provision of open-air schools, and the general co-opera- 
tion with or the correlation of all phases of educational 
hygiene above mentioned. 

OPEN-AIR SCHOOLS 

Open-air schools were found in South Manchester, 
Montclair, Schenectady, Cambridge, Providence, and New- 
ark. Detailed studies of the administration, cost, equip- 
ment, methods and results were made in all cases, but we 
cannot here go into the matter in detail. Readers are re- 
ferred to the excellent reports of some of this work at South 
Manchester, Cambridge, Providence, and Newark. At 
Providence the work is in charge of the Board of Health 
and its enterprising director. Dr. Chapin. Reference is also 
necessarily made to the valuable little book by Dr. L. P. 
Ayres on the subject. 

Open-air schools are not filled with tubercular children 
as many suppose, but with the poorly nourished, the anemic, 
the delicate, and incipient or potential cases of tuberculosis. 
The advantages lie in the way of segregation from other 
pupils of the schools, of special adaptations of work and 
regimen to individual needs, of the good, fresh air, of the 
special loving kindness which is the best medicine for some 
children, of the more natural motor activity, and, especially, 
of better feeding in many cases. It is hard to regulate the 
feeding of selected children in a big school system, but it is 



*See the plan for such work in the last chapter. 



240 SCHOOL HEALTH ADMINISTRATION 

easy when these children are brought together in segregated 
groups and all participate In the same activities. 

Open-air schools are not expensive, but are more costly 
than the usual school system. The expense Is an added one, 
because many or most of the children leave vacant seats in 
the schools. But It Is worth all that Is spent on such pro- 
visions for three reasons, at least: 

a. It shows how necessary fresh air Is in the schools and 
In the homes for all children and all adults. It gets school 
officials and parents to thinking of how to provide natural, 
"uncooked" air to all children at all times. It shows teachers 
that they do not have to live In a torrid, desert atmosphere 
to be comfortable and happy. It shows principals and jani- 
tors that more dependence can be placed upon radiators for 
heating the rooms instead of raising the temperature almost 
entirely by overheating or cooking the air before it goes Into 
the fans and the ventilating flues. It shows that moisture 
should be added, perhaps in the form of steam pans, and 
In large quantities, and adequately registered and regulated 
by accurate humidometers, keeping the air at about 55 per 
cent saturation, and a temperature In the fan room of about 
62 degrees and In the school rooms about 65 degrees 
Fahrenheit. It shows the value of open-window rooms where 
pupils simply keep on their warm wraps, and breathe di- 
rectly the outer air, without recourse to an elaborate fan 
system. But this leads us Into school sanitation In these 
cities, and that is another chapter. 

b. It shows the importance of nourishment for the de- 
bilitated children, and a fundamental essential for all chil- 
dren, besides the fresh air. 

c. The cost is of the nature of a stitch In time saving 
nine. Most children in open-air schools that have been 
followed up carefully for some time after such a school has 
been given up or the children had to leave the school (as in 
the case of the lamented Dr. Arthur T. Cabot's study and 
follow-up work in Boston) have either died in early life or 
Indicated that they had few years yet to live. Long con- 
tinued open-air schooling for a number of pupils will prob- 



PHASES OF MEDICAL INSPECTION 241 

ably raise their resistance enough to make their span of life 
normal and save to society all the expense incurred in their 
upbringing. The work can probably be planned so such 
saving to the school system alone will more than balance 
the cost of open-air schools. 

It is probable, also, that properly devised systems ot 
ventilation in the regular schools and proper attention to 
nourishment, eradicating the coffee-habit, etc., will make un- 
necessary any elaborate extension of such schools. It may 
be well to call them open-air hospital schools and provide 
them for only a few, while placing the greatest emphasis on 
adequately caring for the ninety-and-nine. 

MEDICAL CONSULTATIONS FOR MOTHERS 

The child-hygiene departments of some of our progres- 
sive boards of health begin their care of children with con- 
ception and follow them up in one way or another until the 
age of the work certificate. This is the boast of Boston and 
of several other cities. In Newark, the school medical 
inspection department has provided free medical consulta- 
tion for mothers with Infants or pre-school children. The 
development of this work and the good results which have 
followed show that, without Invading the fields of the health 
department, the school department, through Its medical In- 
spection and whole hygiene department, can help to insure 
the efficiency of the children In the schools long before they 
set foot In even the kindergarten. Such extensions In re- 
sponse to genuine community needs can in the long run be 
only benificent, regardless of the croakings of the wor- 
shippers of the god of things as they were. 

SCHOOL BUDGET EXHIBITS 

For educational and civic purposes, an annual budget 
exhibit In which the hygiene department of the schools Is 
represented, may be of very great value. Hoboken Is the 
only city having had such an exhibit in the year of study, 
among the twenty-five cities. The exhibits consisted of 
charts showing the effects of various ailments on school 



242 SCHOOL HEALTH ADMINISTRATION 

progress a la Ayres, the number of children affected with 
various ailments, the duties of the parents in various direc- 
tions, and a sample of each kind of the medical suppHes on 
burlap screens, with the cost of each below. Those desiring 
to utilize this means of reaching the parents, the tax-payers 
and the children may well correspond with the New York 
Bureau of Municipal Research, which has been the father 
of the movement. 

DISINFECTION OF SCHOOLS AND HOMES 

A good deal of money is spent in this line of prevention 
of the spread of infectious ailments. Montclair has a sys- 
tem of sending formaldehyde gas through the vents of the 
ventilating system, so that a few minutes after an evening 
audience has used a school auditorium, for instance, the 
fumes so fill the room that it is impossible for a person to 
remain in it. Costly paintings hung on the walls of the 
auditorium visited there, but no damage to them or to any- 
thing else seemed to follow. However, with all the work 
and expense, the value of such disinfection is being seriously 
questioned by medical men. The dependence upon this 
mode of prevention is waning, and we very much need 
such studies as those of Dr. Chapin of the Providence Board 
of Health, those of Kerr in London, and of Professor 
Jordan of the University of Chicago.* 

EXAMINATIONS FOR WORK CERTIFICATES 

A number of the cities are coming to a realization of 
the importance of seeing that every child, requesting a work 
certificate at the age of fourteen, is guarded from going into 
the struggle of employment with a poor health equipment. 
Such medical examinations by Boards of Health or Boards 
of Education frequently get treatments where all former 
efforts have failed, and in some cases for the first time dis- 
cover defects that will prove a serious handicap unless prop- 
erly corrected. Boston seemed to be doing most in this 



*See reports, and the 1912 N. E. A. volume, article by Professor 
Jordan giving many references, and bringing up a number of these cor- 
related problems of school infection. 



PHASES OF MEDICAL INSPECTION 243 

field in the year of the study, and the writer learned much 
about the work by watching the examinations, and talking 
with the examiners afterwards. In only rare cases has it 
been necessary to refuse such certificates although many are 
postponed for a time. 

Adequate vocational guidance will of course, in each 
school system, take this health matter into consideration, 
relieving the health department of the obligation. Adequate 
medical inspection throughout school life will greatly lessen 
the need for such service, as a special piece of medical work. 
This of course argues power of compulsion in the lower 
grades, and this is what the New Jersey law grants and 
many cities in one way or another enforce — that parents 
may be compelled to place the child in good health condi- 
tion, or permit the school authorities to do so. Courts, 
truant officers, and cruelty to children societies all work 
together for the benefit of the child where any parent or 
guardian is stubborn in his ignorance. 

HEALTH INVESTIGATIONS BY DEPARTMENTS OF MEDICAL 

INSPECTION 

The work of medical inspection and all health work 
must be placed upon an adequate scientific basis, commensu- 
rate with the newer sciences of medicine and education. A 
city that does not or cannot adequately and accurately meas- 
ure results in this field is condemned at the start. 

Very few cities have made anything like scientific inves- 
tigations of what was being accomplished, what ought to 
be accomplished, or what was necessary to do the work. 
Boston probably made more investigations during the years 
studied than all the other cities put together. If this volume 
does nothing else but show that there are an immense 
number of problems in educational hygiene which demand 
Immediate solution by careful inductive methods, its exist- 
ence will have been justified. 

Some of the problems investigated in Boston were: 

I. The relation of temperature of school rooms to the 
number of cases of anemia found in the rooms. 



244 SCHOOL HEALTH ADMINISTRATION 

2. The relations of ill-health and physical defects to 
retardation. 

3. The ventilation and temperature of school rooms. 

4. A study of 5,000 choreic children, and their school 
progress. 

5. An investigation of the number of tubercular chil- 
dren in the schools, and their environments. 

6. A study of the number of cases of defective vision 
and hearing in the schools, and the number of children wear- 
ing glasses, etc. 

These and other studies were made by this one city. 
Unfortunately none of the studies was carried through to 
completion by the use of such rigorous inductive methods 
as would insure accurate and comparable results, so the 
results of the findings are not here quoted. They were 
regarded as starts only in the right direction, and have not 
all been published by the school authorities in public jour- 
nals, although mention of some of them can be found in 
the Annual Report of the School Committee for 1910. 

The same could be said for the studies of the relation- 
ship of ill-health to retardation in South Manchester, Brock- 
ton, Mt. Vernon, Schenectady, Hoboken, and elsewhere. 
The field is so new and the problems are so complex and 
the requirements of adequate investigation are so great in 
the way of time, labor and ability, or special technique, as 
well as a number of years of study of results, that we have 
as yet little definite knowledge of this health work in the 
schools. And yet there is promise in every study, valuable 
data possibly to lay by, certain tendencies showing them- 
selves, and certain skill and interests arising in the investi- 
gators which are the things to be prayed for if we are to 
get a science of educational hygiene or a science of educa- 
tion. We can close this section with no finer thoughts than 
those expressed by Dr. Cruickshank, now Director of 
Hygiene for the Board of Education of Scotland in his 



PHASES OF MEDICAL INSPECTION 245 

191 1- 1 2 report of medical Inspection in Dunfermline, Scot- 
land:* 

"It behooves them (the Trustees) to renew their Inter- 
est and redouble their energies In seeking to establish thor- 
ough and scientific methods of investigation into the prob- 
lems which bear upon the numerous ailments and nutritional 
deficiencies of the school children of their town. It has to 
be borne In mind that this work Is scientific in the highest 
sense of the term; that It can be done only by those who have 
the necessary scientific training; that It entails much diffi- 
cult and accurate work, and that the results cannot be made 
Immediately apparent, as is the case with the effects of 
treatment. It Is, of course, essential that scientific Investiga- 
tion should both precede and accompany scientific preven- 
tion. The days of empiricism in medical science are over, 
and no true progress can be made In the applications of 
medical science to the problems of education unless their 
points of contact are subjected to minute and accurate in- 
vestigation. In all probability medical science, more than 
any other, will exert an influence on future educational 
movements." 

BOARD OF HEALTH VS. BOARD OF EDUCATION ADMINIS- 
TRATION 

Our data are too Inaccurate and too narrow in scope to 
permit any conclusive statement as whether the boards of 
education or the boards of health should, in general, have 
charge of school medical inspection. As we have gone 
through the various phases of medical Inspection efficiency, 
we have found a number of Instances where In essential mat- 
ters the boards of health, even though they are much older 
In the work, on the average, fall decidedly below the effi- 
ciency of the boards of education. We have attempted to 
get data on enough items by which to rate the various cities 



*The writer has recently distributed lOO copies of this excellent re- 
port bound in boards free of charge to persons in this country known 
to be interested in school health and working for it, and a thousand 
more have been promised by Mr. Andrew Carnegie. 



246 SCHOOL HEALTH ADMINISTRATION 

and the separate divisions in Boston and New Bedford 
where both bodies participate. Some of the most essential 
data we could not get, so the table showing the relative 
ranking of the cities is merely suggestive of a method. It is, 
however, interesting to see how the boards of health place 
themselves at the bottom of the list in the efficiency series. 
My judgment of the probable true ranking of the cities on 
all items, i. e., on their general efficiency, need not be ac- 
cepted.* My best judgment is, however, that, with perfect 
records and accurate efficiency ratings for all elements, the 
ranks of any one of these cities would not be raised or low- 
ered more than five points in the twenty-five. The hardest 
problem in the ranking was to get and decide upon what were 
real efficiency data, and the next hardest problem was the 
relative place of Summit and Newark. The weakness of 
the latter was in the entirely insufficient number of nurses 
in comparison with the number of physicians, and lack of 
provision for high school inspection, while Summit was 
weak in records and used up a large share of the nurse's 
time for the work of attendance officer, though the latter 
is to be commended in general even if it isn't strictly health 
work. Definite steps have since been taken in Newark to 
reverse the numbers of doctors (38) and nurses (8), with 
the doctors to be district supervisors only, while the high 
schools are now pretty well cared for by male and female 
doctors, with nurses. 

The medical officers of boards of health are, of course, 
jealous of their powers, and will not agree with my opinion, 
nor with my data, perhaps. A good example of their point 
of view is given in the April, 19 13, American Journal of 
Public Health in the Report of the Committee on Medical 
Inspection of Schools and School Children, Dr. S. H. 
Durgin, probably the first regular school medical inspector 
of the United States, of Boston, as chairman, and Dr. G. F. 
Kiefer, of Detroit, as acting chairman. They make a strong 
stand for board of health control, but present no data in 
proof and practically no arguments. On other points, their 



*See page 254 for a tentative ranking of the cities on several 
obtainable items. 



PHASES OF MEDICAL INSPECTION 247 

conclusions, based partly on a questionnaire, agree very 
markedly with conclusions already published by the writer. 

The general impression which one gets in going about 
from city to city and studying the work of both departments 
is unstatistical but impressive to the one experiencing it. On 
the whole there is marked contrast in efficiency, with sev- 
eral exceptions, between the two departments, in favor of 
the boards of education. Politics plays a larger part in the 
work of most health boards, and this seems to vitiate much 
of their endeavor. 

To summarize many scattered points we give below some 
of the chief: 

ADVANTAGES AND DISADVANTAGES OF BOARD OF EDUCA- 
TION AND BOARD OF HEALTH ADMINISTRATION 
OF MEDICAL INSPECTION 
I. BOARDS OF HEALTH 

A. Advantages. 

1. They can, if efficient, knit up school health with the 

general health problem. 

2. They can medically inspect parochial and private 

school pupils as well as public school pupils. This 
Boards of Education can do only where state laws 
laws force parochial schools to obtain adequate 
medical inspection. It is then relatively easy, as 
in Milwaukee, for the boards of education to 
get control of this important service. 

3. They can employ medical inspectors on full-time, 

giving them other public health work during a 
large part of the time. 

4. They can keep physicians and nurses in touch with 

all phases of the health problem in the city and 
community, by having them share in the work of 
infant-mortality education in the summer, district 
nursing of adults, infectious disease quaran- 
tine, etc. 

5. Where there is an efficient, interested superintendent 

of health, not too much engrossed with other 
health matters, there is a possibility of more ex- 
pert supervision of school doctors and nurses, and 



248 SCHOOL HEALTH ADMINISTRATION 

more progress toward a wide range of curative 
and preventive measures, than in a school system 
where the school superintendent has no medical 
specialist as supervisor of educational hygiene or 
of medical inspection, and is himself little inter- 
ested or learned in school hygiene. 

B. Disadvantages. 

1. They seem to be more under the dominance of par- 

tizan politics, and not as efficient as are the boards 
of education. 

2. They introduce an extraneous element into the 

schools, making it impossible to get the best kind 
of co-operation on the part of teachers and prin- 
cipals in health work. 

3. They make impossible the organization of all the 

five divisions of educational hygiene into one or- 
ganic department. 

4. They do not seem to get the money and the support 

for medical inspection, as well as do the boards of 
education. 

5. They look upon the school health work in a more 

limited way, generally, e. g., from the standpoint 
of infectious diseases, or merely that of finding 
the ailments of children. Curative and preventive 
measures, and the treatment of the child, his 
health and his education, as a whole can hardly be 
obtained, and are little emphasized by such boards. 

6. They seems to be weaker in the way of educating 

the parents through school meetings, medical in- 
spection, pamphlets, etc. 

7. They very largely omit complete physical examina- 

tions of the children. 

8. They are especially weak in providing an adequate 

number of school nurses, in comparison with 
boards of education. Counting Boston and New 
Bedford, and leaving off the first three of our 
cities, making 1 1 boards of education and 1 1 
boards of health participating in this work, we 



PHASES OF MEDICAL INSPECTION 249 

find the sum of the nurses for the boards of educa- 
tion is 59, while the sum for the boards of health 
is only 16. Boston now has over forty nurses and 
other boards of education have been increasing 
their numbers. The ratio now would show a 
greater disparity. Our cities do not well show 
this tendency because they were selected on the 
basis of their having nurses. In proportion to the 
number of pupils and using the data for the entire 
country given by the Sage Foundation we should 
have a far greater disparity. The Boards of 
Health Committee, above mentioned, strongly 
urges the use of school nurses, however, and rec- 
ommends as many as three nurses for each doctor, 
and, at least, one for each 1,500 to 2,000 pupils, 
and only one physician for each 3,000 pupils, 
where he gives only part time to the work as they 
recommend further. 
9. The best types of medical inspection records, re- 
ports, and statistics are being devised by boards of 
education and they are using nomenclature that is 
more easily understood by the people to whom 
reports are made than those made by boards of 
health. However, in these cities we find in two 
places the ailments of children given in greater 
detail and in better organized form, than is the 
case with most of our board of education reports. 
Cleveland and Newark, on the board of education 
side, and Providence and Boston on the board of 
health side would stand out in this one particular. 
10. Board of health administration of school medical 
inspection is contrary to the tendencies of the 
times, most cities taking up the work in recent 
years putting it into the hands of the school offi- 
cials, and whole states, with the unfortunate ex- 
ception of Minnesota, going in this direction, e. g.. 
New Jersey. The problem evidently will soon be 
a dead issue except for scattered cities in the east- 



250 SCHOOL HEALTH ADMINISTRATION 

When states get general directors or Supervisors 
of (Educational) Hygiene, as many soon will, we 
shall have the agencies in the school departments 
to make board of health administration unneces- 
sary anywhere. 

11. BOARDS OF EDUCATION 

A. Advantages. 

1. The work can be done by boards of education with- 

out loss to them or to the boards of health and 
without as great waste of public expenditure. The 
boards of education can supervise the health con- 
ditions while individuals are immature and in pub- 
lic schools with good means of control. Boards 
of health can do the same for individuals in pri- 
vate life; and, according to Winslow, in his excel- 
lent article in the June, 19 13, North American 
Review, this will soon be extended to factories 
- , and other institutions where individuals congre- 

gate. In this article also, "Efficiency in the Pub- 
lic Health Campaign," the day is foretold when 
most if not all medical work will be public and 
not private work. This tendency will add so much 
to the boards of health that the work of the 
schools will not seem so large in comparison. 

2. Our data seem to show that, in general, these, and 

perhaps most, boards of education take up this 
work with more energy and general efficiency, 
with marked exceptions, of course. 

3. The work can be integrated with both the scholastic 

and the general physical development of the pupils 
better when in the hands of one board, the board 
of education necessarily, than when the work is 
divided up. Schools must discover their own 
health needs in order to do away with the present 
isolation of parts and to go about physical educa- 
tion, school sanitation, etc., in a rational manner. 

4. The work can be done more cheaply to the city, not 



PHASES OF MEDICAL INSPECTION 25 1 

only because of the greater efficiency of boards of 
education but because the introduction of super- 
visors of hygiene as herein planned will make pos- 
sible several economies and the avoidance of need- 
less dupHcation of efforts by the two boards. 

5. As is now done in New Jersey, boards of health 

can medically inspect parochial and private 
schools, leaving to the boards of education the in- 
spection in public schools. Whether boards of 
education should take over the inspection in 
these outside schools is a question. France and 
Germany exercise a great deal of control over 
such institutions, making them conform to general 
state requirements, and it will undoubtedly be 
necessary to place the inspection of all school chil- 
dren in the hands of the public educational 
authorities. 

6. Boards of education seem to get better support from 

the public, although they do not have the powers 
over the people in general held by boards of 
health. The schools are closer to the public purse 
and will be more apt to make the work progress 
as it should. 

8. They emphasize the ailments which, though not 

directly or immediately death dealing, are, never- 
theless, very serious in their effects, and yet are 
largely neglected by boards of health. 

9. The number of part-time doctors with no other 

school health work can be greatly reduced. Super- 
visors of hygiene and more nurses will help solve 
the problem, and the time will soon come when 
the entire medical force in the schools will in some 
way be made full-time workers like the teachers. 
Physical education and departmental teaching of 
hygiene may be mentioned as probable occupation 
for the time not spent in physical examination 
each day. With a morning of three hours daily 
for medical inspection and examination this would 



252 SCHOOL HEALTH ADMINISTRATION 

leave only the short afternoons to provide for. 
Educational hygiene courses, abridging the long 
M. D. preparation and physical education train- 
ing, may make possible the introduction of such 
men at salaries around $i,8oo to $2,000. Full- 
time workers are undoubtedly to be desired, 
though we have no data with which to prove it. 
B. Disadvantages. 

1. At present, lack of competent medical supervision 

of the work of doctors and nurses. 

2. Lack of control over parochial schools, with the pos- 

sibility of uncontrolled infection in these schools 
spreading to the public schools. 

3. Lack of correlation with the general health prob- 

lems of the community such as the control of mid- 
wives, milk and water purity, infant mortality, 
tuberculosis, infectious diseases, and general extra- 
school health difficulties. 

4. Lack of sufficient police and compulsory power in 

forcing parents and guardians to place their chil- 
dren in reasonable health condition for school 
attendance, in most places. 

5. Possibility of under-emphasis of the health factor 

by an institution traditionally specialized for 
mental and scholastic development. 

GENERAL 

In general, we conclude that while for the present there 
are a number of cities where this work is now in the hands 
of excellent men, such as Dr. Chapin of Providence, and 
may well remain there for a time, and while It Is desirable 
for cities, rural communities, and states to keep the work 
In the hands of boards of health for the benefits of variety 
and testing of these suggestions, still, for the most part, and 
for all cities and states taking up the work for the first time, 
and for any localities where it seems quite evident that the 
work should be taken out of the hands of the boards of 
health, — In all these places, the administrators of medical 
inspection of public schools should be the boards of educa- 
tion. 



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PHASES OF MEDICAL INSPECTION 255 

MEDICAL SUPERVISION OF HIGH SCHOOL PUPILS 

As before mentioned, the health of high school pupils is 
very much neglected and this part of our school system is 
yet very much of a mere intellectual and academic machine, 
running by mediaeval and formal-discipline formulae. In 
preparing the section on The Hygiene of the High School 
for Professor Johnston's new book on High School Educa- 
tion, Volume Two, Scribner's, the author has been interested 
to go more deeply into the health problem of the high 
school. As I show there, the best data obtainable, from 
Newark and from Washington, D. C, as well as from my 
study in Montclair, disclose the fact that there is a surpris- 
ing amount of sickness and physical defectiveness in the high 
school population. Carrying through the fifty-four classes 
of ailments, summarized as to frequencies among a thousand 
elementary pupils in the last chapter, we find that the high 
school figures are close up to those for elementary pupils. 
We are by them reminded of G. Stanley Hall's statement 
in his volumes on Adolescence that the high school period is 
a period of a low death rate but of a high morbidity, or 
sickness, physical defectiveness, rate. 

Our high school pupils are to be the leaders in their 
respective communities and they should be fitted for efficient 
leadership by adequate health protection and education while 
in school. Nothing less that careful, scientific and rigid 
medical supervision will ever show our high school teachers, 
too, that pupils of this age are other than disembodied men- 
talities and book-reading machines. 

I have called attention to valuable statistics on this prob- 
lem in Professor Johnston's volume. I give here the results 
of work done by Dr. Thos. Storey with the young men in 
the secondary and lower collegiate departments at the Col- 
lege of the City of New York, reprinted from the Pedagogi- 
cal Seminary for December, 19 12. Dr. Storey has also 
shown by his records that such medical inspection and ex- 
amination does not throw an excessive burden upon the free 
dispensaries and clinics but furnished In the year ending 



256 SCHOOL HEALTH ADMINISTRATION 

June, 191 1, patients for 1,100 professional men who re- 
ceived over $12,000 compensation. (See the Proceedings 
of the Sixth Congress of the American School Hygiene 
Association.) 

RESULTS OF DR. STOREY's FOLLOW-UP SYSTEM OF MEDICAL 
INSPECTION OF HIGH SCHOOL STUDENTS 

The success of this "follow-up" system during the year 
ending June i, 19 12, may be seen in the following statistics: 

1st term 2d term 

Number of boys given instructional advice 105 1 936 

Number of diagnoses followed up 1542 1409 

Number of conferences necessary to follow up all cases. 2244 1925 

Number of "diagnoses" recorded as "under treatment". 73 158 
Number of "diagnoses" recorded as having "secured 

treatment" 1298 1093 

Number of "diagnoses" recorded as having "refused 

treatment" 11 10 

Number of "diagnoses" recorded as having "promised 

treatment" , 108 102 

Left college 48 40 

Number of parents refusing to secure treatment 9 8 

Number of individuals warned 328 290 

Number of individuals debarred 71 92 

Number of individuals reinstated 67 85 

Number of individuals that remained debarred 4 7 

Number of dentists consulted privately 273 256 

Number of physicians consulted privately 189 139 

Number of opticians consulted privately 22 16 

Number of dental clinics attended 3 4 

Number of hospitals attended 24 14 

Number of students securing private dental service 320 310 

Number of students securing private medical service... 204 147 

Number of students securing the service of opticians. ... 15 18 

Number of students securing free dental service 8 13 

Number of students securing free medical service 4 5 

Number of students securing free clinical service 

(dental) O 3 

Number of students securing free clinical service 

(medical) 10 II 

Number of students securing service of optician free. . . o o 

Total number securing private service 539 475 

Total number securing free service 22 32 

Total number for whom home treatment was sufficient. 490 429 
These statistics justify the following conclusions : 
First. Our medical inspection is effective. It is securing the repair 

of physical defects, and it is correcting unhygienic conditions in over 



PHASES OF MEDICAL INSPECTION 257 

ninety per cent of the cases in which such treatment is desirable. This 
plan of individual instruction in personal hygiene is improving the 
physiological efficiency of at least a thousand boys every half year. 

Second. Our plan of individual instruction in personal hygiene has 
met with the support of the parents of practically all our boys. Less 
than one per cent of the parents refuse treatment. No system can 
endure without such support. 

Third. It is safe to expect that this continued personal relationship 
extending throughout the high school period and covering the first two 
collegiate years will develop permanent habits of personal health con- 
trol in many if not in most of the boys under our supervision. 

GENERAL CONCLUSIONS REGARDING MEDICAL INSPECTION 

I. The administration of medical inspection in these 
twenty-five cities is extremely variable and yet there are evi- 
dences of certain norms or standards toward which progres' 
sive school systems are more or less slowly evolving. The 
problem of the dissertation is to discover these standards 
and to develop others, more scientific and sociological, in 
order that conscious evolution may soundly abridge much of 
the tedious process of hit and miss, and avoid great indi- 
vidual and social waste. This heterogeneity is shown in a 
variety of ways, not as an intensive study of any narrow 
phase but sweepingly in the nature of a broad survey in ac- 
cordance with the nature of the entire study, 

A. The size of the city has little to do with the number 
of medical inspection agents, although the two largest cities 
in a number of particulars have almost the same propor- 
tionate number of units, doctors and nurses, as the smallest 
cities. 

B. To enable comparison among cities as to number of 
working units of medical inspection forces, the following 
factors were added together for a unit: Physicians: aver- 
age number of hours a day, average number of days a week, 
average number of weeks in the year, average number of 
hours yearly actually employed in school medical work, 
including clerical work, plus the nurse. The quality of the 
work and the standing of the physicians in their profession, 
as well as the amount of school time spent in making out 
records and reports and the amount spent in traveling about 



258 SCHOOL HEALTH ADMINISTRATION 

from school to school, could not well be determined. Even 
the number of days annually in which doctors made school 
visits could not in all cases be learned. The work varies for 
physicians from an average of a very few hours a year, 
probably less than fifty, up to two hours a day for each 
school day in the year (say 350 hours) , and some give three 
hours daily though not so regularly, while the nurses' hours 
are very close to a standard of a five-and-a-half day week of 
seven to eight hours daily. 

C. The variability is great in the forms of administra- 
tion and execution of the work. Some cities, like Brockton 
and Norwood, almost eliminate the physician, while others, 
like Newark, put the emphasis upon the physicians, although 
the tendency is strongly toward placing the work more and 
more in the hands of well trained school nurses. Some cities 
have the work in the charge of the boards of health, others 
in charge of boards of education, while others divide the 
work between the two departments. We have studied cities 
that have no doctors and others that have no nurses for 
comparison. Some cities have only inspection systems of a 
limited kind (for infectious diseases) while others have sys- 
tems much broader than inspection and including annual 
physical examinations, cumulative record cards, adequate 
reporting, and great emphasis upon curative and preventive 
measures. All-round school clinics are only being agitated 
as yet. 

D. The variability might also be illustrated by the 
tables of ailments and the very different proportions for any 
one ailment from zero to sixty or more per hundred chil- 
dren. 

II. The cost of medical inspection also varies greatly as 
shown for salaries. The average salary for physicians is 
about $400 with great variations, while the salaries of 
nurses is near $75 a month for the school year, and some for 
the summer, one or two months. Supervisors' salaries range 
from $800 up to nearly $4,000. Only one board of health 
has a special supervisor of this work, and he gets the lowest 
salary. A city may be paying very small salaries to its school 



PHASES OF MEDICAL INSPECTION 259 

physicians and yet be paying more than a city with a large 
annual salary, when the amounts of time spent during the 
year in actual school medical work are compared. Other 
expenditures for medical inspection are as yet very small 
because of lack of free clinical treatment. The total expendi- 
tures and relative expenditures are given in the tables. 
Adequate systems, as here recommended, will cost from one 
to four per cent of current expenditures. Scientific reor- 
ganization of many existing systems of educational hygiene 
as a whole need cost little more than is at present spent for 
a variety of uncorrected health provisions. 

III. Methods and technique of Inspection are very 
chaotic, and most reports of the work are so inaccurate 
and meaningless as to be practically worthless. Little can 
as yet be said as to what medical inspection Is accomplishing 
for schools. Record systems need greatly to be simplified 
so efficiency will be promoted, not discouraged. Medical 
inspection must be correlated with all other phases of edu- 
cational hygiene: medical Inspection, physical education, 
school sanitation, the teaching of hygiene, and the hygiene 
of teaching. The work has and should broaden out beyond 
"Inspection" to include annual (physical) examinations and 
generous curative and preventive measures. Medical Su- 
pervision of Schools would be a good term to cover all 
phases, but the writer does not urge its adoption because of 
the difficulty of getting the name generally used. Health 
Supervision will not do because this describes the scope of 
the entire department of hygiene, and may be confused with 
the city health department. The chief criticism of methods 
will be found in the last chapter in the form of a plan for 
doing the work efficiently and well. We have avoided draw- 
ing deadly comparisons and of showing up as much Ineffi- 
ciency as possible. Most cities are willing to make desirable 
improvements when they see that they are Improvements. 
The final chapter meets this need better than any amount of 
muck-raking. The tables are largely self-explanatory. 

IV. The no7nenclature and the classification of school 
ailments and the various phases of medical inspection should 



26o SCHOOL HEALTH ADMINISTRATION 

be widely adopted for promoting reasonable uniformity and 
greater efficiency. The plan of placing the curative work 
of the nurse in juxtaposition with the cases found by nurse 
or physician should be adopted. Some of the essentials for 
each ailment are as follows : 

1. Number of new cases (serious, not minor) found and 
referred for treatment by (a) the doctor, and by (b) the 
nurse. 

2. Number of old cases inspected by (a) the doctor, 
and (b) the nurse. 

3. Number of these cases which were found negative by 
family physicians and agreed as such by the school physician 
or nurse. 

4. After subtracting the negative cases (where the diag- 
nosis has been determined wrong or the child not needing 
treatment), the total number of new and old remaining^ yet 
to be followed up until treated and cured. 

5. The number of cases (ailments, perhaps several for 
some children) (a) treated by the nurses of school clinic, 

(b) treated by other agencies, (c) cured. 

6. Number of children excluded for the various ail- 
ments, counting only one ailment as causing exclusion, num- 
ber re-excluded after presenting themselves at the school, 
and (c) the number re-admitted after illness, exclusion, 
quarantine, absence of three days or more, and the number 
admitted for the first time, after the first two weeks of 
school, i.e., after the routine September room-inspection of 
all school children. 

7. The number of remaining cases (ailments) not yet 
(a) treated, (b) cured. 

The classified list of ailments later recommended as a 
beginning standard should be placed at the left of the page 
for the report, weekly, monthly or annually, with the above 
rubrics as headings. Other significant data are given on the 
alternative recommended weekly report of the nurse for 
the work of the doctor and herself. This type of report, 
when well used will balance. 



PHASES OF MEDICAL INSPECTION 261 

V. Few of the cities yet have annual medical examina- 
tion of all elementary pupils; and Boston and South Man- 
chester, Conn., were the only ones that had done much in 
the high school field. Medical examination and even inspec- 
tion reaches but a small proportion of the total number of 
children in the schools, and, although many cures are re- 
ported in certain cases, the results in this direction are very 
meager. Free school clinics are recommended. 



CHAPTER TEN 

PHYSICAL EDUCATION AND OTHER PHASES OF 
EDUCATIONAL HYGIENE 

Following a simple working classification of the various 
divisions of educational hygiene, we have now completed but 
one phase or department, that of medical inspection. The 
short section on Conclusions on Medical Inspection has at- 
tempted to bring together in succinct form the chief results 
and principles arising from our study of the health pro- 
visions in the twenty-five cities chosen for this investigation. 
There remain yet for consideration and study the following 
divisions: Physical Education, School Sanitation, The 
Teaching of Hygiene, and the Hygiene of Teaching. In 
this chapter we can give but briefly the main data and con- 
clusions arrived at in the study of these phases in these 
cities. 

In an investigation of school health provisions, medical 
inspection naturally comes first, since it, more than anything 
else, points out those pathological weaknesses of our chil- 
dren which it is the main business of most of the other 
divisions to prevent and correct. If the work of doctors 
and nurses shows that a large percentage of the children 
are poor in health and bodily efficiency, that they are living 
unhygienically at home and at school, and that they suffer 
from a whole host of preventable ailments, then we have 
clearly laid before the whole school system and all the 
homes their problem and duty relative to health. Medical 
Inspection can do much in the finding of ailments and In their 
cure. It can by no means cover all the fields of prevention 
In the form of: 

I. Improving the school environment, hygienlcally, 
through school sanitation; 

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264 SCHOOL HEALTH ADMINISTRATION 

2. Promoting normal physical development, vital resist- 
ance, and certain indispensable health habits and ideals, 
through physical education; 

3. Giving adequate health education, including knowl- 
edge, habits, ideals, and appreciations, to the children of the 
schools and through them to the homes. 

4. Managing and teaching the children in the most 
hygienic manner, making the methods of teaching and the 
life of the school such as will promote health and happiness, 
prevent rather than cause physical defects, and given the 
nation what Dr. Burnham calls a "militia of health" instead 
of inefficient and unreliable candidates for the sanitarium.* 

A. PHYSICAL EDUCATION 

A tremendous development of physical education has re- 
cently taken place in the form of the playground movement 
and all that it implies, and in the beneficent reaction upon 
the old, stilted, fatiguing, isolated, and unnatural formal 
gymnastics inherited from military and autocratic sources. 
We have shown in a former chapter the tremendous devel- 
opment of this new form of life and activity for children. 
Like all of the other new health agencies which have re- 
cently been crowded into the public schools largely by lay 
bodies from without, we have here another illustration of 
a lack of integration with all other health agencies of the 
schools, of adequate scientific leadership and control, and of 
proper scientific management and economy. Like many 
other health provisions, too, the play movement Is still quite 
largely In the private and voluntary stage of development. 

The principal phases of this form of physical education 
found by the writer were : 

I. Increased playground space, not only by and near 
the schools, but In parks, vacant lots and other places, and 
provided by playground commissions, park commissions 
and many private agencies. The natural play center Is, 



*See "The Problems of Child Hj^giene," by W. H. Burnham, in the 
1912 volume of the proceedings of the N. E. A. 



DIVISIONS OF HYGIENE 265 

of course, at the school, also the best place for community 
parks. 

2. Increased school- and factory-made play apparatus in 
school yards. 

3. Folk dancing in charge of special instructors em- 
ployed for this work alone at the schools. 

4. School athletic leagues in increasing numbers. 

5. Emphasis upon more democratic and better directed 
athletics in the high schools. 

6. After school and Saturday direction of play and ath- 
letics of elementary children by school masters. 

7. Increased number of gymnasiums in the new and old 
school buildings. 

8. Increased number of physical training teachers and 
supervisors. 

9. Increased number of evening recreation centers, 

10. Emphasis on the provision of skating rinks for 
school children in winter. 

11. Increased attention to the educational value of play 
and to its correlation with other motor activities such as 
industrial work, especially in vacation schools. 

12. Increased attention to the direction of the recess 
and other free play periods of school children. 

13. Increased number of summer playgrounds and play- 
ground instructors and directors. 

14. Emphasis upon swimming and bathing for school 
children, especially in the summer. 

15. Growing use of play festivals, pageants, and the 
like. 

It might have been well for us to have carried through 
rigorously the exact amount of work in all health fields that 
each city gave during the years studied. Comparisons, how- 
ever, may be helpful and they may be odious, according to 
an old saying. We shall be content if we have sketched a 
method of analyzing the health work of a city, and shown 
even vaguely how efficiency tests may be applied to them. 
We studied in some detail the cost, equipment, workers, 
methods, and results as well as they could be learned of all 



266 SCHOOL HEALTH ADMINISTRATION 

play agencies, public and private, in the cities chosen. But 
we cannot give here all the details necessary for discriminat- 
ing and comparative work. We do give in the following 
table the main public school physical education expenditures, 
including, of course, playgrounds summer and winter. 

Any examination of this table will show that a consid- 
erable number of cities are doing little or nothing in a spe- 
cial way for the physical development of the school children, 
and that it is only in the largest city, Boston, that we find 
any extended development of physical development agencies 
that seem at all adequate either in the old Greek or modern 
sense. Many cities had no physical training teachers, play- 
ground instructors, or even ten- or fifteen-minute periods 
during the school days for school room cahsthenics or games. 
In some schools and cities there has even been a tendency 
toward cutting out the good, old-fashioned recess, of so 
much value in a physical way to the children. It is difficult 
to state a number of these facts by cities, for occasional 
schools may be held up as exceptions in almost any city, and 
any general statement, unless favorable, may be resented. 

On the other hand, the general tendency is strongly in 
the direction of increased health provisions, and a study of 
the reports of these school systems for the four years from 
1909 to 19 1 2, inclusive, has shown some almost radical 
transformations in this direction. Such statements as the 
following are significant, in the first report (1910) of Dr. 
Hermann, then Director of Physical Education at Cam- 
bridge: "We have instituted both a morning and an after- 
noon recess (italics mine), which are taken out of doors 
whenever the weather and the yard conditions are favor- 
able. Without this, only the most active children would get 
sufficient exercise, and the teachers would not have the 
opportunity to study their charges while at play." 

Particularly marked development along these lines has 
taken place in New Bedford, Trenton, Cambridge, Newark 
and Boston. 

Beginning again with the whole department of physical 
education, not including play and playgrounds, we found 



DIVISIONS OF HYGIENE ' 267 

the following phases, in one or more of the cities, to analyze 
out and study: 

1. General Director of Department of Hygiene, at 
Boston only (lacking here only the school physicians, to 
make the department complete). 

2. Assistant directors of physical education, three at 
Boston and two at Newark. 

3. Supervisors of physical training or of physical edu- 
cation, largely the former, having only restricted duties, not 
having general oversight. 

4. Elementary school teachers of physical training, 
play, folk dancing, and all that the subject now includes, 
number and salaries. 

5. High school teachers, or "directors" of gymnasiums, 
gymnastics, athletics, physical examinations, and the like, 
number and salaries. 

6. Clerical assistants for several of these departments, 
number and salaries. 

7. Military drill masters, assistants, and armorers, 
number and salaries and the work of the cadets. 

8. Number of school gymnasiums, elementary and high 
schools, including separate drill halls, and the like. 

9. Cost of equipment and maintenance for these. 

10. Number of gymnasiums used for evening recreation 
work. 

11. Number of swimming pools, shower, and tub baths 
in elementary and high schools. 

12. Number and salaries of bath matrons, and special 
janitors for baths. 

13. Number of outside public or private baths open to 
school children. 

14. Two-minute or ten- or fifteen-minute recreation, 
play, or callsthenic exercise in the class-room by regular 
teachers. 

15. Salaries of special repair men for gymnasiums. 

16. School athletic leagues, their hand-books, their 
membership and expenditures, private and public. 



268 SCHOOL HEALTH ADMINISTRATION 

17. Special coaches in athletics in high or elementary 
schools. 

18. Substitutes in physical education and their manage- 
ment and salaries. 

19. Number of lectures to pupils on physical develop- 
ment and general health topics. 

20. Employment of sub-masters for directing play after 
school and Saturdays, Boston. 

21. Efforts in the field of medical gymnastics. 

Tables when made on the basis of most or all of such 
divisions, as proved the case for all other phases of educa- 
tional hygiene, and even for the compact table of school 
ailments made for medical inspection — isuch tables were 
pretty much blank spaces, not only because of the hetero- 
geneity of the work as yet, but also for the reason that 
many school systems have not yet engaged themselves seri- 
ously with the problem of physical education. We are still 
very far from the Greek ideals of harmonious bodily effi- 
ciency. A revolution must gradually be worked in the idea 
of public education itself before schools, school curricula, 
and school administration are adjusted to the health and 
bodily needs of the children of urban civilization. This will 
be pointed out more particularly under the hygiene of teach- 
ing. Much of the promise in the cities here studied lies in 
the construction of new school buildings, planned, not for 
disembodied mentalities, nor for rural children getting 
fairly adequate physical and motor development in the out- 
of-school life, but for the cooped-up, sedentary, in-door, 
flat-dwelling children, limited within by the restrictions of 
apartment-house and school life, and without by the dangers 
and policemen of the streets. That such a life as is rapidly 
developing in this country will speedily kill off, through the 
law of survival, all those unadapted to it and leave a people 
healthily adjusted to such conditions, may only partially be 
looked to, for the simple fact of the lower birth-rate in cities 
and the need of constant replenishment by country folk. 
Beside this force and possible eugenic control there must be 
rigorous and radical transforming of the environment and 



DIVISIONS OF HYGIENE 269 

education of the rising generations, especially at the schools. 
Adequate health education may be expected to react upon 
the health conditions of home and business life, making them 
in turn more hygienic and healthful.* 

PHYSICAL EDUCATION SUPERVISORS 

Thirteen of the twenty-five cities could be said to have 
had at this time supervisors or directors of physical training, 
but in only three or four could these officials be regarded, 
perhaps, as directors of physical education. A person who 
merely teaches physical training in elementary or high 
schools, and who has no general responsibility for or super- 
vision of all forms of physical education such as mentioned 
above could hardly be called a director or supervisor of 
physical education. We should probably put Cambridge, 
Newark and Boston in this class, and perhaps others. We 
have listed as supervisors, however, ten others with more 
limited responsibilities. A person may well be supervisor 
of physical training or of physical education in the ele- 
mentary schools or in the high schools alone, but such divi- 
sion leaves an uncorrected system.* 

The salaries at South Manchester and Winchester are 
for part-time services. The salaries really range from 
about $1,000 to about $4,000, the director of hygiene at 
Boston receiving at that time $3,800, and the assistants 
about $2,400 each. At Yonkers, no one physical training 
teacher seemed to be supervisor and no report on physical 



*I do not wish to suggest here that country children are not in 
need of radically improved hygienic conditions. In making this study 
the writer traveled over a large portion of New England, New York 
and New Jersey in street cars, thus coming close once more with coun- 
try folk; and the most vivid impression of the people met was that of 
their low physical efficiency. Of course urban and western selection 
has taken off most of the vigorous, physically superior individuals, as 
the wars of Europe have cut off its stronger and abler types, but after 
subtracting this influence we must admit the possibility of raising con- 
siderably the hygienic conditions of country life. See also Gillette's 
"Constructive Rural Sociology." 

*See the excellent chapters in Johnston's High School Education 
(Scribner's) on "Physiology and Hygiene," and "Sex Pedagogy in the 
High School" and other chapters in Vol. H. 



270 SCHOOL HEALTH ADMINISTRATION 

education appears In the 1910-11 annual report. Seven 
cities, apparently, had no special teachers in this field. In 
Rochester the supervisor is employed for the work of 
directing the summer playgrounds, and this is also true of 
Boston. There, the services of the director are for eleven 
months. In Boston and Newark, all officials in this field 
of work are on a salary schedule, with minimum and maxi- 
mum salaries. This Is highly desirable, as is also, for the 
most part, the twelve payments a year plan. 

ELEMENTARY SCHOOL TEACHERS OF PHYSICAL TRAINING 

After subtracting the supervisors, so-called, we have 
but few special teachers of this subject left for the element- 
ary schools. It is also a problem whether many or most 
of these cities need many such teachers. In another chapter 
the author has evolved a plan by which a physician with 
knowledge and experience in physical education may be 
employed by a city or several small cities or a country 
township or county, and given the directorship of all five 
phases of educational hygiene, thus making possible the 
elimination of much of the present expenditures for poorly 
trained medical examiners and physical training supervisors. 
The present physical directors in the high school gymnasi- 
ums should be retained, and, If need be, one or more phy- 
sical training teachers for the elementary schools. If com- 
petent nurses are employed for about each 1500 to 2000 
school children they may be given also the present work 
of the attendance officers; no general directors of summer 
playgrounds need be employed, except In cities large enough 
to have assistant directors ; fewer part-time physicians need 
be employed, as suggested; and in all, for a great many 
cities, a re-organized and efficient system, correlating all 
health agencies, may be obtained, even when paying the 
general physician-director $3,000 or more, for little more 
annual expense than under the present poorly directed and 
un-organlzed plans of management. The writer knows of 
twenty-five available and qualified men for such positions 
now. More young physicians will take the training neces- 



DIVISIONS OF HYGIENE 271 

sary when a demand is evidenced. We probably need 
more Doctors of Public Health (D. P. H.) rather than 
so many Doctors of Philosophy (Ph.D.). The possible 
saved expenditures in this direction for these cities should 
be subtracted from the estimates of needed hygiene officials 
given in table XII. 

Besides the ten or more physical training teachers for 
the elementary schools, Boston had a most interesting ex- 
periment in the employment of 60 male teachers of the 
schools (sub-masters) to go out with the boys to the parks 
and playgrounds after school and Saturday mornings to 
direct them in their sports. Each teacher is paid $1.25 
extra for each period, six a week, and the whole scheme 
has seemed to be eminently successful. 

Instead of giving the amounts expended for such teach- 
ers and high school directors in the two largest cities, 
we give only the minimum and maximum salaries, the 
teachers being at different points in the schedules as was 
the case of the 35, and now 41 or more, nurses in Boston, 
and the eight in Newark. Wherever two or more teachers 
or directors are recorded their combined, and not their 
separate, salaries are given. Thus the two assistant super- 
visors at Newark received $1,100 and $1,400 respectively, 
or $2,500 together (maximum, $2,000) ; and the three 
teachers at Rochester received a combined sum of $3,300. 
This would also apply to Yonkers, and also to the play- 
ground teachers in several places. 

Like the school nurses, the physical training teachers 
are practically all graduates of special schools or depart- 
ments for such work. We found only one nurse who 
had only the qualifications of a regular grade teacher (at 
Lowell) and we found only one teacher of physical train- 
ing who had "just picked it up." It is easy today to get 
superior training in this field, but not in the field of medical 
inspection, and there are still no schools for the education 
of directors of hygiene which will abridge the medical 
course, leaving out much in such special fields as obstetrics 
and adult treatment as will not function and putting in 



272 SCHOOL HEALTH ADMINISTRATION 

much left out by the regular medical course. We are not 
aware that the University of Wisconsin has provided prepa- 
ration for this service in its new health department. Teachers 
and directors can now obtain a good library and can get 
a good summer course on the medical aspects of their work. 

HIGH SCHOOL TEACHERS OF PHYSICAL TRAINING 

Eleven or more of the twenty-five cities had one or 
more teachers of physical training in the high schools.* 
Most of the newer high schools were being supplied with 
gymnasiums, as well as many of the new elementary schools, 
and generally we found at each high school thus equipped 
a man for the boys and a woman for the girls conducting 
the department. In some cases, as at Montclair and 
Lowell, outside buildings have been rented or purchased 
for such provisions. The $500 salary at Lowell was for 
the part-time services of a drill master for the boy cadets. 
In this city, Boston, Brockton, and a few other cities, more 
or less attention is being paid to this form of health de- 
velopment, largely for high school students. It is much 
more military in character than the Boy Scouts scheme, 
and probably not so valuable. The cadets in Brockton, 
however, take trips somewhat as do the Boy Scouts. Both 
have uniforms, but with a difference. Of one of these suc- 
cessful cadet organizations Professor Wm. H. Burnham, 
the dean of educational hygienists in this country, has this 
to say: 

"A few weeks ago it was my privilege to witness the 
parade of the high school cadets of Boston, a parade of 
two or three thousand school boys. It was an excellent 
exhibition of the results of careful drill and organization. 
The cadets did credit to themselves and to their military 
instructors. But as I observed them as they marched, I 
noticed how many were sallow in countenance, anemic, or 
flat chested, or mouth breathers, or apparently suffering 



*See Gulick's study of the "Status of Physical Education in 90 
Public Normal Schools and 2,392 Public High Schools in the United 
States." Fourth National School Hygiene Congress. 



DIVISIONS OF HYGIENE 273 

from some physical disorder or defect or bad condition; 
and how few had the ruddy glow and the general aspect 
of health that the adolescent should exhibit. These were, 
however, in a certain sense, the pick of the pupils in the 
public schools. 

"If this is the price that must be paid for education, 
it is no wonder that parents are dissatisfied and that they 
ask whether the reward is worth the sacrifice. What man 
of sense would bargain vigorous health, normal develop- 
ment, and a few motor accomplishments like those of the 
Boy Scouts for a little conventional book-knowledge and 
anemia and ill-health and mal-development?" 

He furthermore recommends* that drill in health habits 
be substituted in part for the special drill in military tactics, 
and the development, not of a kind of police force, but of 
"a militia of health trained to fight the conditions of disease 
by the methods of modern science." 

This is but one step in the complete socialization of 
the whole physical education department. With scientific 
and medically trained people in charge, we may expect 
studies to be made of the health needs and health problems 
of the students and the people of the community in order 
to make education hit the mark. What physical education 
seems to need is a great deal more of scientific and socialized 
intelligence, rather than special motor accomplishments. 

We made little or no study of athletics and athletic 
coaches. The football, basketball, track meets, and all 
the various forms of outdoor and indoor competitions fur- 
nish specially acute problems which take special investiga- 
tion and time in each city. Most of the progressive de- 
partments are now working for or have attained, athletic 
fields, stadiums, and all the paraphernalia of the college. 
With proper re-organization of the high school curricula, 
throwing out the immense quantities of deadwood that have 
accumulated for ages of formal discipline theories, and with 
the introduction of thoroughly essential educational activl- 



*See 1912 volume of the N. E. A., page 1102. 



274 SCHOOL HEALTH ADMINISTRATION 

ties, we may expect these health fields and equipment to 
provide thoroughly democratic and general physical and 
social development of the old Greek type and better. 

MEDICAL EXAMINATIONS AND EMERGENCY TREATMENT 

In all first-class high school departments of this kind, as 
in normal schools and colleges, physical examinations and 
emergency diagnosis and treatment are attempted. The sad 
fact, however. Is that most high school gymnastic directors 
are not properly qualified for such work. In asking them 
for their views on medical Inspection, they nearly always 
request that the physicians make their heart and lung ex- 
aminations for those going into athletics because they "do 
not feel properly qualified"; they do not have a medically 
trained eye always to notice fairly obvious indexes of phy- 
sical defects and other ailments; and so, instead of being 
the health guardians of the high school, able to discover all 
health Impediments to education and to act as general 
medical and sanitary Inspectors of the school, we have them 
occupying a little Isolated niche. Such a lack of medical 
qualifications. Is, of course, very expensive to the school 
system that tries to do the best for the hygiene of the 
school. The male physician-director of the normal school 
can adequately examine his pupils, with their clothing re- 
moved, for heart, lung and other examinations, and the 
woman physician director can also adequately examine and 
inspect, when necessary, her pupils. Trouble arises when 
this is attempted by outside or part-time physicians, and the 
only economical method in the long run will be for these 
two or more teachers who meet all the pupils perhaps 
every week, to be physicians, or have special medical knowl- 
edge, and do the work of medical examination and Inspec- 
tion. Many illustrations from life could be given of the 
even fatal results coming from having under-educated health- 
development teachers in charge of this vitally essential work. 

Boston gets around this difiiculty partly by having 
qualified persons in the high schools, partly by having special 
physicians employed for medical examinations in the high 



DIVISIONS OF HYGIENE 275 

schools, and partly by having a director of hygiene who 
is also a physician. The last is a part of the essentials 
of the plan proposed by the writer in the next chapter. 
Let us not forget that under the proper kind of a director 
of hygiene these high school directors may be taught to 
do this work satisfactorily in many cases. We have in- 
stances where regular teachers, working with school phy- 
sicians, have acquired rare powers in this direction. 

GYMNASIUM AND GYMNASIUM BATHS 

At least sixteen or seventeen of the cities had baths in 
one or more of the schools, elementary and high, but mostly 
the latter, and both tubs and showers, but mostly the latter. 
South Manchester each year gives a good report of the 
school baths, and we find that at one school during 1910-11 
as many as 12,858 baths were taken. In all modern schools 
where there are gymnasiums or where there are equipped 
playgrounds adjacent, we found one or more shower baths 
for both boys and girls.* We found that about the same 
number of cities had gymnasiums as had baths, although 
they are not co-incident. These are relatively modern 
additions to schools and school boards have not yet been 
made to realize the truth for school children, many with- 
out bath tubs or parents with bath ideals at home, that 
"cleanliness is next to Godliness." 

In a growing number of cities, through the use of bath 
rooms in schools for summer playgrounds and for evening 
recreation centers, there is a tendency for public school 
baths to become general public baths, and there is little 
reason why this should not become universal, just as much 
as the tendency for the school to have within it a branch 
of the public library or any other of the many agencies 
which are being developed in response to the peoples' needs. 
Too often our schools are looked upon as absolute, un- 



*For those interested in the various types of equipment for these 
health features the reader is referred to the excellent reports and adver- 
tisements in the School Board Journal, published at Milwaukee. 



276 SCHOOL HEALTH ADMINISTRATION 

changing and unchangeable Institutions, instead of institu- 
tions purchased by the hard toil of the many, and sup- 
plementary institutions, now idle much of the time, for meet- 
ing the peoples' needs and perplexing life problems. We 
need scientific sociologists who can discover the needs, and 
we must have teachers and leaders who can best help the 
people to meet them through this single public neighbor- 
hood institution. 

The many other phases of physical training we shall 
not here discuss. They are sufficient in all for a much 
needed book. A recent valuable one along this line but 
more for adults is "Exercise in Education and Medicine," 
by Professor R. Tait McKenzie, of the University of 
Pennsylvania. We should have liked to take space for dis- 
cussing the work of medical gymnastics along the line of 
mouth breathing exercises, special exercises for spinal cur- 
vature cases, and the like. Let us turn our attention, how- 
ever, briefly to the before-mentioned work of: 

PLAYGROUNDS AND PLAYGROUND TEACHERS 

The following interesting and relatively statistical 
phases of this new movement were given as much study 
as possibilities of time and available data permitted : 

1. Number of school-yard playgrounds fitted up with 
play apparatus and the number supervised, summer or 
winter. 

2. Number of these playgrounds fitted up or supervised 
by outside agencies. 

3. Number of playgrounds elsewhere provided by the 
board of education. 

4. Number of other public supported playgrounds, 
swimming pools, or beaches. 

5. Number of privately supported playgrounds, other 
than those at the schools. 

6. Expenditures for salaries of playground directors, 
teachers, caretakers, etc., by the board of education. 

7. Expenditures for playground apparatus by the board 
of education. 



DIVISIONS OF HYGIENE 277 

8. Expenditures for enlarging old or purchasing new 
playgrounds, grading, and the like. 

9. Expenditures for playground supplies other than ap- 
paratus. 

10. Expenditures for the rent of playground sites. 

11. Expenditures for tents, shelters, toilet conveniences, 
baths, etc. 

12. Number, qualifications, and salaries of playground 
directors or supervisors. 

13. Number of assistant directors, salaries, etc. 

14. Number of playground instructors, salaries, etc. 

15. Number of weeks employed, and daily and weekly 
time schedules. 

16. Number of instructors for each playground and how 
selected. 

17. The games, contests, sports, and problems of the 
work. The writer was once a public playground instructor 
and realized some of these problems in advance. 

18. Number of regular class-room teachers who by any 
inducement, such as the $1.25 at Boston, could be gotten 
out upon the playgrounds with their children to be young 
again and play. "Come let us play with our children." 

19. Total expenditures for public school playgrounds. 

20. The methods by which the various private bodies 
realized their aims in getting playgrounds started in the 
schools. 

These and a number of other problems were first ob- 
tained in note-book, and other original data form, and then 
placed on a statistical table for the twenty-five cities. But 
it was so much a table of gaps, that it could well be used 
for study only, and not for printing. A few of the many 
items necessary for adequate knowledge and careful investi- 
gation appear in the Physical Education table. 

New Bedford and Boston stand out in the writer's mind 
and data as being typically progressive along these lines, 
though several other cities such as Rochester and Newark 
might also have been named. The data were so hard to get 
that in many cases we have very inadequate facts or none 



278 SCHOOL HEALTH ADMINISTRATION 

to present. In other cases we have been able to get all the 
data we desired. This seemed especially true of New Bed- 
ford, where a good deal of scientific management seems 
to pervade the school administration. 

Very few cities outside of Boston have been doing much 
with the directed and organized play during the day ex- 
cept in summer. It is difficult to get teachers for their own 
or the children's good to go out and play at any time, 
without pay. In most cases they need special training for 
such work. The many children who come to school, and 
should come, as early as eight o'clock in the morning and 
who stay, and should stay (because of bad home or play 
conditions elsewhere) till four or five in the evening, should 
have guidance, protection and educative care. The in- 
creased health efficiency of the teachers and the decrease 
of teacher-absence through illness, now so great a source 
of waste in all cities, might easily be sufficient to warrant 
a city for mere economy to employ, as does Boston, these 
out-of-school play teachers. Walks, trips, excursions, 
"tramps," and the like, on Saturdays, have all been tried 
by the writer as a school principal and were found success- 
ful, and might easily be added to the above program. The 
school system of Gary, Indiana, is working out much in 
the line of the whole day and year school, that many edu- 
cators have long experienced as a real need of childhood. 

A remarkable thing was the number of privately sup- 
ported playgrounds. This has recently been a very popular 
form of private philanthropy, and should be heartily en- 
couraged and guided. But the goal of it all must be, of 
course, adequately organized public management of such 
agencies. It is remarkable how much the leadership of 
the superintendent of schools stands out in all these fields 
of enterprise. Some are excellent, old-time scholars, or 
"hale fellows well met," but they don't see the need or 
get the results which a modern community may rightfully 
expect. 

The summer playgrounds are frequently about eight 
weeks in duration and are often intimately united with the 
vacation schools, as they should be. The salaries range 



DIVISIONS OF HYGIENE 279 

from fifty to two hundred dollars a month. The tremend- 
ous development of literature in this field makes unneces- 
sary detailed statements of costs or methods. The National 
Playground Association of America with its proceedings, 
and its magazine, the Playground, the books of Bancroft, 
Mero, Johnson, Perry, Leland, Lee, and many others; the 
pamphlets, slides, free information, etc., of the Child Hy- 
giene Division of the Russell Sage Foundation, and many 
other expert agencies at the command of public school 
systems desiring assistance have made unnecessary here ex- 
tended treatment. It may be well briefly to describe the 
administration in the New Bedford public school play- 
grounds. 

A skilled playground director was brought from Toledo, 
Ohio, and the following force employed for six weeks on 
eight playgrounds in the summer: 

I supervisor at $200. 

8 directors, one for each playground (men).. $600 — $75 a term. 

8 first assistants (women) 480 — 60 a term. 

8 second assistants (women) 750 — 75 a term. 

8 men assistants 800 — lOO a term, 

8 caretakers, or janitors 240 — 30 a term extra. 

The plan was to have four persons on each playground. 
There were swings, sand boxes, large combination ap- 
paratus, teeters, slides, merry-go-rounds, rest rooms fitted 
up with interesting books for the children by the public 
library and the schools, use of school toilets and baths, 
trees and benches for the parents and little mothers, and 
first-class conditions, generally. At night electric arc lights 
illuminated the grounds and directed play was still carried 
on, especially basketball and athletic games and "stunts" by 
the older boys and young working men, I saw no evidence 
of home-made, or manual-training-made apparatus, which 
I think should be encouraged and which I have found school 
boys even below the eighth grade quite able to construct 
when properly guided, from getting the materials from 
the mills to digging the holes and painting the constructions 
bottle-green. All the apparatus was very finely constructed, 
durable and expensive. It seems that where there is time, 



28o SCHOOL HEALTH ADMINISTRATION 

home blacksmiths could make most of the apparatus of 
playgrounds for which present companies are charging 
almost exorbitant and seemingly trust prices. The boys 
should in every case possible be given, also, a chance to 
show their hand. 

Having reached our space limit for the various forms 
of Physical Education, let us take a brief survey of one 
of the three remaining divisions of educational hygiene in 
these cities. 
B. School Sanitation. 

Recent surveys of the hygienic aspects of the school 
environment of our children by the LInited States Govern- 
ment and other agencies have shown that they are in gen- 
eral far below the health ideals, knowledge and standards 
of the present day. One writer has declared that it would 
be a hygienic providence if half of the vilely constructed 
and situated school-houses of this country were to burn 
down, in order to make possible school environments suited 
to present-day needs and conditions. The writer visited 
one or more, and as many as ten, school buildings in each 
city visited, excepting the fifteen not used for this study. 
Some of the new schools are very close to the best hygienic 
ideals, and their numbers are fortunately growing. We 
should have state laws requiring the submission of all plans 
for school buildings to an expert, up-to-date school architect 
In the state education department, to help cities avoid the 
employment of so-called architects who have never planned 
anything much more elaborate than a sawmill, or common 
warehouse, and these only by copying imitatively some long- 
existing structure. 

Our chief method was to learn about some of the more 
administrative aspects of the school sanitation problem. 
Some of the features investigated more or less closely 
were: 

1. The number, kind, cost and efficiency of the various 
types of sanitary drinking fountains installed. 

2. The kinds, number, cost and efficiency of the vacuum 
cleaning plants in use, discarded or proposed. 



DIVISIONS OF HYGIENE 281 

3. The number and kinds of fan systems of ventilation 
in use, the attempts to humidify the air, the use of humi- 
diometers and regulators of temperature and moisture. 

4. The new types of school seats which make cleaning 
easy, and especially the use of vacuum cleaners. 

5. The construction, location and arrangement of open- 
window rooms in schools. 

6. The amounts, kinds, efficiency and cost of the floor 
oils used. 

7. The amounts, kinds, efficiency and cost of dust-ab- 
sorbing compounds used in sweeping, as well as the use 
or non-use of the feather dust-raiser. 

8. Paper or cloth towels, number, cost, kinds, and effi- 
ciency. 

9. Amounts, kinds and use of disinfectants for schools. 

10. The use of individual drinkings cups, and how cared 
for. 

11. Experiments and investigations in the field of school 
sanitation. "Re-circulation" has not yet reached the 
schools. 

12. The general hygienic character of the buildings vis- 
ited, including fire-proofing, and all the various modern 
improvements for making cleanliness easily possible. 

13. General management of the cleaning and janitorial 
service, and how paid, feudally or individually. 

A large amount of data was collected on these phases 
but the matter makes but poor statistical tables because of 
the aforesaid lacunas. 

There was some remodeling of the heating, ventilating, 
toilet, and other sanitary provisions in old schools of a 
number of systems, Syracuse and New Bedford being espe- 
cially busy along this line, it seemed. 

Sanitary drinking fountains were found in practically 
all school systems, but in many, these were only samples 
sent in by various companies in hopes of an Order. South 
Manchester, Norwood, Winchester, Montclair, Hoboken, 
New Bedford, Cambridge, and Boston had them in almost 
every, or in every school. The Keith bubbler seemed most 



282 SCHOOL HEALTH ADMINISTRATION 

used and satisfactory, although a host of other types were 
being tried out. The writer saw fifteen or sixteen that had 
been placed over the watering troughs of the boys' play- 
room in one school in Jersey City. Only one or two were 
still "in the ring," as the boys said. One or two had been 
taken off because of the breaking of children's teeth on 
them in the jostling crowd. The following requirements for 
such fountains seem to stand out: 

1. They must be very strong and durable, not getting out 
of repair, nor weak enough in any part to be screwed or 
pulled off or apart. 

2. They must provide cool water, not warm, in a sani- 
tary manner, with no part touching the pupil, if possible, 
that is not immediately washed off. A small leak, or a plan 
for turning the water on and off by the janitor, or the pos- 
sibility of running out a large amount of water quickly "to 
get down to the cool" is necessary. 

3. They must be in batteries and over troughs to pro- 
vide for many children, without making a flood on the 
floor. 

4. They must be safe, so no child may be cut, get his 
teeth broken, or anything of the kind even when pushed 
about. Good janitor service and training are necessary 
here also. 

5. They must not be very wasteful of water, although 
considerable loss is here expected. 

6. They must be placed on every floor, or one in every 
room, as well as in the basement play-rooms. Plenty of 
pure water is desirable for children. 

7. They must be relatively inexpensive, although certain 
cities bought very costly porcelain standards and fountains 
at great cost. 

8. It should be made impossible for one child to squirt 
water over an entire group or hall. 

9. If placed out of doors it must not rust and it must 
not freeze. 

10. It should be self-closing; and the bubble or fountain 



DIVISIONS OF HYGIENE 283 

of water should not rise at any time more than one and a 
half inches.* 

The prices range around three to six dollars apiece, al- 
though the porcelain standard one, such as used in Mont- 
clair in a new school, costs about fifty dollars apiece. New 
Bedford paid $1,093 ^or 117, connected and in place, I 
believe. 

VACUUM CLEANING PLANTS 

Very few cities were using vacuum cleaning plants in 
the schools. South Manchester was the only city using them 
in all schools, and the 1909 report of the superintendent 
speaks very highly of them. I saw the method of using 
them in the high school and agreed that they probably were 
very desirable. The newer schools in Newark are utilizing 
them. Montclair has a building piped for their use but 
has not yet put in the apparatus. The piping can be easily 
done in new but not in old buildings, so putting them in is 
wise foresight, it seems. Waterbury was tearing up the 
high school to get pipes in when I was there. Boston had 
three such plants, two having been installed in the year. 
Rochester had put a plant in several years before (1908) 
in a grammar school, but it had proved useless because of 
the faults of the apparatus perhaps, but more because the 
head janitor was paid a lump sum, and the women helpers 
he employed could not manage the apparatus. "It was 
more bother than it was worth" to them. There are easier 
and dustier ways. Careful investigation and experiment, 
careful selection of janitors on other than the feudal sys- 
tem, probably, careful training of janitors in the use of 
the apparatus, carefully constructed floor (we need com- 
position floors that are effective), and careful selection of 
fewer-legged desks and seats are all necessary for the best 
use of vacuum cleaners. 



*The School Board Journal above referred to has many advertise- 
ments and cuts of various makes, and any school system can easily get 
the chance to try out any number desired. Such experimentation is 
desirable before purchasing. 



284 SCHOOL HEALTH ADMINISTRATION 

SANITARY SCHOOL DESKS AND SEATS 

Real educational school desks will probably be, as in 
the University of Chicago model school, work benches or 
combination working desks, movable, adjustable and with 
movable seats. Such desks are not used. The usual type 
has four or more legs close to the floor and screwed 
down. This is the child's stationary stall, for silent, seden- 
tary, bookish work. It does not meet the needs of the all- 
around school life. However, there are school desks and 
seats that have all the disadvantages of being stationary and 
fixed, and without some of the "new-fangled notions" of 
combination work-bench-desk, but having, alas, the quality 
of being adjustable to the child, that can be swept under 
and kept in sanitary condition. I refer to the oval base, 
single-pedestal combined seat and desk invented by a Boston 
janitor and improved upon and sold in the market by a 
well-known seating firm. Here is only one pedestal for 
each child in the room instead of four. When poorly put 
down they become "wobbly," and the boy in front can spoil 
the writing of the boy behind, but this insecurity is unnec- 
essary. The Moulthrop movable school chair is also be- 
coming popular. 

Adjustable desks were used in only a part of the cities 
and in only a part of the schools. A city may reply to a 
questionnaire that it uses adjustable desks and have only 
a few in use. This is a weakness of the investigation re- 
ported in Chapter Two. 

In Boston, the School House Commission has always 
been in the lead of most cities in problems of school archi- 
tecture and sanitation. It has done most in the way of 
devising the proper kinds of windows in south-exposed 
rooms, for open-air rooms. It also sent a deputation to 
Chicago to study open-window and open-air schools there, 
"with little profit." It has also done most in the study 
of humidifying the school atmosphere, and the lack of 
agreement among experts in ventilation consulted has al- 
most brought matters to a standstill until the problem is 
less obscure. There are, however, examples of humidifiers 



DIVISIONS OF HYGIENE 285 

and regulators that seem to work to great advantage, as 
at the Horace Mann School, Teachers College, Columbia 
University. A steam pan is used, and several barrels of 
water are sometimes used in a day in keeping up a 55 per 
cent saturation, and a 65 degree class-room temperature, 
all automatically regulated by wet bulb and dry bulb humidi- 
ometers by the Johnson Service Company. 

FLOOR OILS 

Floor oils are quite commonly used, and are bought for 
from ten cents to more than a dollar a gallon. Experiments 
and analyses at Rochester and try-outs at West Orange 
seemed to show that there was little difference between oil 
of the two prices. A city could get about the same oil for 
the price it wished to pay. We very much need adequate 
experimental testing of many more or all of the various 
kinds of school supplies and equipment. We need better 
use and test of what we get, as well as "more money for 
public schools." 

Oil carefully put on, left to dry, and then wiped off with 
cloths, during a two or more days' vacation has in a more 
or less scientific manner been found very desirable in keep- 
ing schools clean, and little complaint from women teach- 
ers about their skirts have arisen. In the writer's own 
school the women teachers voted to have oiling stopped, 
but after an experiment of three or four weeks voted to 
have it renewed. The matter has been tested out in various 
ways. We need a careful experimental and adequately con- 
trolled test of the whole method. Some insist on bare floors, 
others on oiled floors. Differences in floors and jani- 
tors count, but the matter can be comparatively and experi- 
mentally proved. 

DUST ABSORBING COMPOUNDS AND SPRAYS 

It is remarkable what a variety of products are used 
in this field. It is encouraging to see something of the 
kind used, but again we have little proof of the value of 
any one kind over others. About twenty of the cities used 



286 SCHOOL HEALTH ADMINISTRATION 

damp sawdust or one or more of the various kinds of 
no-dustos, dustalines, no-more-dust, sprays (Rihac), etc. 
What must be had is the experimental testing of these 
expensive theories. Perhaps damp sawdust is sufficiently 
efficient. Perhaps it would be cheaper to put in vacuum 
cleaners. Perhaps oil brushes are better. Who knows? 

PAPER VS. CLOTH TOWELS 

Paper towels seem easily to be winning out over the old 
common cloth towel. Many cities were trying them, and 
some cities, like New Bedford, Montclair and others, had 
definitely adopted them for all children. They are now 
so cheap, so thoroughly individual, so sanitary, and so 
effective, if well chosen through experimental testing, that 
there is no longer any excuse for the old, indecent, filthy 
and generally de-educating lack of proper sanitary neces- 
sities yet so common. We teach and preach to our children 
in the classrooms about the dangers of carriers and Typhoid 
Marys, and then fail to provide conditions which will make 
possible the acquisition of anti-Typhoid Mary habits in our 
class and toilet rooms. Every child should have warm 
water with which to wash his hands, liquid soap for the 
inevitable grime of the real playground and real boy, good 
absorbent paper towels, satisfactory arrangements for 
plenty of good drinking water obtained without danger to 
life and limb ; clean, well-equipped and sufficient toilet facili- 
ties, a drying and warming place for himself and his clothes 
when he comes wet and cold to school (perhaps without 
breakfast, or one of only coffee and bread) , a place to clean 
his shoes and insistence on it, a place to hang his clothes 
that is warm and dry and supplied with hooks that keep 
the clothing and possible contagion far apart instead of 
huddled together for the benefit of scarlet fever, diphtheria 
and very much larger germs. The only kind of health 
knowledge and hygiene for our pupils is the kind that mill 
eventuate in adequate health habits, and how many schools 
even fairly meet the simple essential sanitary standards 
above named? Entirely too few. 



DIVISIONS OF HYGIENE 287 

We must close the report of this division. Better sani- 
tation is approaching slowly, and for its slowness there is 
a reason, convincing to the writer, and to be given at the 
end of the chapter. 

C. The Teaching of Hygiene. 

We meet the same situation in the field of the teaching 
of hygiene, a form of knowledge, habits and ideals much 
more important in the modern world than probably three or 
four entire subjects now tremendously emphasized "for 
their formal disciplinary value" in our high schools and 
probably one or two in our elementary schools. And yet 
the subject is a tail-end subject, little emphasized, and fur- 
nished with poor textbooks for the most part and very 
frequently with poor teachers in the grades or high school. 
Colleges do not generally give credit for, nor demand a 
knowledge of, this vitally essential subject of health and 
how to get and maintain it, much to their disparagement, 
and consequently we find many schools almost entirely 
neglecting it.* And yet the cadets march by, with sunken 
chest and defective eye, all but those who have dropped 
by the wayside through death and illness; and the medical 
inspectors continue to report their ailments by the thousands. 
The problems of the people are the problems of education. 
Health is a prime problem, and health knowledge measuring 
up to our needs today is one of those alphabetic concepts 
which every child must have whether he ever sees a gram- 
mar or an algebra or a Caesar or a geometry or a moderr 
foreign language in his life. 

Health teaching is in these cities evidently "seriously 
defective," in the words of the New York School Inquiry 
Report, and most educators today are realizing it and 
gradually beginning to introduce pragmatic changes. 

I learned in most cities how much time was given to 
the subject of hygiene in all grades, elementary and high 
schools, and the texts used. We shall not repeat here the 
names of many of the texts. In the older days of logic, all 



*See Johnston's High School Education, volume one. 



288 SCHOOL HEALTH ADMINISTRATION 

our subjects began with the anatomy of the subject, the 
dry-bones, so to speak, the formal grammar, the letters, the 
parts of a letter in penmanship, celestial mechanics in geog- 
raphy, the bones of arithmetic, etc. One of the old books 
on "Anatomy and Physiology for Children," or some such 
title actually started out with a chapter entitled, "Dry 
Bones," and all the 206 with their good points were to be 
learned by heart, with never a mention of how to live 
healthily and happily in this world. Then came the physi- 
ology period, when we learned some anatomy and much 
of the chemistry of digestion and respiration, etc. Today 
the subject is at last becoming socialized and changed from 
a logical, abstract science to a vitally essential scientific art, 
ministering to the health needs of our people. Some of 
these older texts are still being used in the cities visited, 
and in very few of the cities in elementary or high school 
is the subject given the time and texts which its known 
value warrants and demands. 

The Ritchie Hygiene series and that by Gulick and Jewett 
seem at present to be in advance of all others. We found 
them used in but ten cities. In most of the other cities 
where I had an opportunity to talk with the superintendent 
on the matter of school hygiene texts, I found books from 
one of these two suggested series either ordered, about to 
be ordered, or actually being experimentally tried out in a 
few rooms. Probably a search of the present book lists of 
these cities would show better supplies of more modern texts. 
One subject of great importance but little taught is that 
of industrial hygiene. Another is sex hygiene. 

Teachers are not adequately trained in this subject in 
most normal schools and consequently have not the interest 
In, or such a knowledge of, the subject as Is desirable. 
Lacking health education, and in their comparative isola- 
tion from the problems of life, we find that they cannot 
clearly see "what knowledge is of most worth" to their 
pupils. The modern world is becoming aware of Its health 



Note. — Colton's new book on "The People's Health" by Mac- 
millans is a very valuable contribution to upper-grade texts in hygiene. 



DIVISIONS OF HYGIENE 289 

heritage and health knowledge now possessed by but a few 
is rapidly coming to be democratized, so we may expect 
soon the most rapid changes toward meeting the real needs 
of real life. Good textbooks are indispensable for the 
best results for American teachers in general, and their 
selection, as well as the time allotment, are matters for 
close study. 
D. The Hygiene of Teaching. 

This division of educational hygiene is usually called 
"the hygiene of instruction," but instruction is only a part 
of the teacher's work and the life of the school. The 
French are wont to contrast instruction and education. The 
German or French teacher instructs all his classes all day 
long. The American teacher gives time for individual 
study, self-help, and individual guidance, for teaching in 
the best sense, and so we use the term, the Hygiene of 
Teaching. 

A teacher may teach hygiene for such long periods or 
in so dry and dismal a way as to over-fatigue and depress 
her pupils. She may teach splendidly the subject of tuber- 
culosis in a school-room with all windows tightly closed and 
the air so thick and vile that little lungs easily become sus- 
ceptible to the germs she teaches the children to dread. 
She would have taught better had she opened her windows 
in a proper manner. Again she may be teaching quite effec- 
tively, from the intellectual side, the hygiene of vision, and 
yet the print of the books she has placed in her pupils' hands 
may be so atrocious that most children suffer from eye- 
strain after the study period; or again her curtains may be 
so arranged that with well printed books and good teaching, 
she may be injuring her pupils' eyes by bad lighting, while 
discussing the danger. All these are mistakes in the hygiene 
of teaching and there are multitudes more which the un- 
hygienically trained teacher will make continually in any 
few days of time. 

Other topics in this field, but not studied in the inves- 
tigation because of the room-to-room character of the work, 
are : fatigue, school program, one session or two sessions, 



290 SCHOOL HEALTH ADMINISTRATION 

recesses or no recesses, rest periods, the type of books, the 
adjustment of the daily surroundings of pupils to their 
bodily needs, the health results of marks and examinations, 
the teacher's responsibility for the increase of defects of 
vision, for choreic, anemic and debilitated children, the 
development of healthful habits and interests, and ways of 
study and doing work; in general, the most harmonious 
guidance of the school life of the pupil and his fellows, in 
order that there may be a real hygiene of living, a hygiene 
that "will make growth more perfect, life more vigorous, 
decay less rapid, death more remote." 

CONCLUSIONS 

In this chapter we have taken a rapid survey of the 
last four divisions of educational hygiene as practiced in 
these cities, and as they should have been practiced. We 
have found them in a transitional stage and changing in a 
few years from a more static, isolated attitude toward the 
problems of school health, to a more socialized, scientific 
and democratic attitude. Some of the cities will probably 
be little further advanced in the next decade, but the most 
of them will before long undoubtably make most of "the 
things hoped for" an actual realization. 

The principal drawback, as I see it, is neither the lack 
of money nor the backwardness of the people and the 
superintendent, but in the gap existing In practically each 
school system that should be filled by a person specially 
intelligent, responsive and able in health matters. The 
ordinary superintendent probably does not give a large 
fraction of one per cent of his time and energy to the prob- 
lems of educational hygiene. He and his supervisors and 
his teachers are otherwise engaged. The intellectual aspects 
of life are those which absorb his and teachers' energies. 
He appreciates somewhat the health needs but he does not, 
or can not, take time for them. The solution of the health 
problem in the schools will come, as we have seen all along 
throughout the book, only in the appointment of a thor- 
oughly qualified man, educated in medicine and school hy- 



DIVISIONS OF HYGIENE 291 

giene, and given the entire management and responsibility 
for the health aspects of education. Only then, I believe, will 
health become a reality in our schools, and educational 
hygiene now In Its Infancy become a scientific art. 

The following chapter brings all the suggestions of the 
book together In the form of a rather detailed and prac- 
tical plan for reaching this much-to-be-desired goal, in the 
adequate administration and reorganization of all the divi- 
sions of educational hygiene. 



HEALTH EFFICIENCY THROUGH NOR- 
MAL EDUCATION 

With the increasing socialisation of education 
we may look forward toward a more normal 
mental and physical life for school children. The 
older methods of sentencing growing children for 
many years to sedentary book-reading in sta- 
tionary seats are beginning to pass away. Chil- 
dren are no longer looked upon by the best 
teachers and administrators as mere disembodied 
mentalities, but school life is becoming an all- 
round life largely consisting of useful, socialising 
and energising motor work and play. The school 
grounds are becoming community parks and 
recreation centers taking the place of the village 
green of the olden times; the school building is 
being transformed into a house of childhood ade- 
quately adapted to the real nature of children and 
the needs of society; and the old Greek spirit of 
all-round joyous efficiency is coming by a new 
birth again into its oivn.. We need many more 
experimental schools that, like Tuskeegee, Abbots- 
holme, Inter-laken, and the various consolidated 
farm schools, ivill lead the way into this broader 
and less artificial education. Health efficiency 
through normal living is an actual possibility. 



292 



PART THREE 

THE ADMINISTRATION OF MEDICAL INSPECTION 



(Part three may also be had in separate pamphlet 
torm for the use of teachers, nurses, doctors, etc. The 
blank forms herein described may be purchased in 
quantities from the publishers. Teachers College, Co- 
lumbia University, Publication Department, New 
York City.) 



293 



ENLARGING SCOPE OF THE SCHOOL 

"The complete pedagogy of the future when 
it comes will he larger than it has yet entered 
into the heart of any man to conceive. Thus the 
present situation should appeal to the best young 
men as education has never before appealed. All 
the four or five score of child-helping-welfare 
agencies must and will he correlated with the 
school and directed from one central bureau, so 
that each child can be placed just where in the 
whole system it will get the most good. Each, 
too, will not only he inspected medically and 
morally, hut studied for vocational aptitudes." — 
G. Stanley Hall, in Introduction to "Educational 
Problems." 



294 



CHAPTER ELEVEN 
THE ADMINISTRATION OF MEDICAL INSPECTION 

A TENTATIVE STANDARD PLAN 

I. GENERAL ORGANIZATION 

A. Each school system able to afford it, and few can- 
not, should have an organized Department of Hygiene, 
with a Supervisor of Hygiene, correlative with other super- 
visory departments in the schools. It should be called the 
Department of Hygiene to avoid confusion with the depart- 
ment of health oi the city. It need not be entitled the 
"Department of School Hygiene" for the same reason that 
the department of drawing is not called the department of 
school drawing. Neither need it be called the "Department 
of Hygiene and Physical Training," nor any other such 
combination. The word Hygiene is as broad as Health 
and may be used to cover all health agencies of the public 
schools, namely: 

1. Medical Inspection. 

2. Physical Education. 

3. School Sanitation. 

4. The Teaching of Hygiene. 

5. The Hygiene of Teaching. 

The function of such a department is to coordinate and 
make efficient through organization, inspiration, and super- 
vision all the heterogeneous agencies for the promotion of 
the health and normal physical development of the school 
children. 

SCOPE 

A large number of the more or less neglected problems 
of school health and national vitality would thus come 
within the scope of this department, among which may be 

295 



THE DIVISIONS OF EDUCATIONAL 

HYGIENE 

Supervisor of Hygiene 



MEDICAL 
SUPERVISION 



SCHOOL 
SANITATION 



PHYSICAL 
EDUCATION 



TEACHING 
HYGIENE 



HYGIENIC 
TEACHING 



NURSES AND 
DOCTORS. 

INSPECTIONS 
AND ANNUAL 
EXAMINATIONS 

SCHOOL 
CLINICS. 

HEALTH 

CENSUS. 

DISCOVERING 

HEALTH 

NEEDS. 

CO-OPERATING 
WITH BOARDS 
OP HEALTH 
AND PRIVATE 
ORGANIZA- 
TIONS. 

OPEN AIR 
SCHOOLS. 

LIMITING 
DOCTORS TO 
EXAMINA- 
TIONS, 

SUPERVISION 
OF NURSES 
AND WORK 
IN CLINICS. 

PSYCHOLO- 
GISTS, 
OCULISTS, 
SURGEONS, 
DENTISTS, 
PHYSICIANS. 

SUPERVISION 
OP SCHOOL 
FEEDING. 

SCIENTIFIC 
STUDIES OF 
PREVENTION 
AND CAUSE 
OF DISEASE. 

CAREFUL 

RECORDS 

EMPHASIZING 

SERIOUS 

AILMENTS 

FOUND AND 

CURED. 

TRAINING 
SCHOOL 
NURSES FOR 
ALL INSPEC- 
TION AND 
EXAMINATION. 

NURSES AS 

ATTENDANCE 

OFFICERS. 



SCHOOL SITES 
AND ARCHI- 
TECTURE. 

VENTILATION. 

LIGHTING. 

HEATING. 

DRINKING 
WATER AND 
FOUNTAINS. 

SCHOOL 
CLEANING. 

VACUUM 
CLEANERS. 

SCHOOL 
BATHS. 

HYGIENIC 

TOILET 

FACILITIES. 

SCHOOL SEATS 
AND DESKS. 

DECORATION. 

THE STAND- 
ARD SCHOOL 
ROOM. 

FIRE-PROOF 
CONSTRUC- 
TION. 

HEALTH, REST, 
AND EMER- 
GENCY ROOMS. 

PLAYROOMS 
AND ROOF 
PLAYGROUNDS. 

OPEN WINDOW 
ROOMS. 

SUPERVISION 
OF JANITORS. 

HYGIENIC 
CLOAK ROOMS. 

DRYING AND 

WARMING 

SEATS. 

INVESTIGA- 
TIONS OF RE- 
CIRCULATION, 
HUMIDITY. 
AIR-CLEAN- 
ING, DISIN- 
FECTION, ETC. 



PLAY AND 
PLAYGROUNDS. 

PHYSICAL 
TRAINING 
AND GYM- 
NASTICS. 

MEDICAL 
GYMNASTICS. 

ATHLETICS 
AND LEAGUES. 

POSTURE AND 
CORRECTIONAL 

EXERCISES. 

ASSISTING 
IN MEDICAL 
SUPERVISION. 

RECREATION. 

SCHOOL 
EXCURSIONS 
AND TRAMPS. 

BOY SCOUTS 
AND CAMP 
FIRE GIRLS. 

GYMNASIUMS 
AND ATHLETIC 
FIELDS. 

SWIMMING 
AND BATHING. 

POOLS, SHOW- 
ERS AND 
BEACHES. 

POLK 
DANCING. 

PHYSICAL 
EDUCATORS 
WITH MEDICAL 
KNOWLEDGE. 

HIGH SCHOOL 
CADETS. 

CLASS ROOM 
GAMES. 

PAY FOR 

SUPERVISING 
PLAY AFTER 
SCHOOL AND 
SATURDAYS. 

CULTIVATING 
THE GREEK 
IDEAL OF 
PHYSICAL 
AND MENTAL 
PERFECTION. 



HEALTH EDU- 
CATION OP 
TEACHERS. 

ADVISING 
CHOICE OP 
BEST HYGIENE 
TEXTS AND 
TOPICS. 

FORMING 
PERSONAL 
HYGIENE 
HABITS. 

PUBLIC 
HYGIENE 
STUDY AND 
CO-OPERATION. 

HEALTH EDU- 
CATION OP 
PARENTS. 

FEEDING, 
CLOTHING 
AND SLEEP 
OP CHILDREN. 

HOME HYGIENE 
IN DOMESTIC 
SCIENCE. 

VOCATIONAL 
HYGIENE IN 
INDUSTRIAL 
SUBJECTS. 

TALKS BY 
DOCTORS, 
NURSES AND 
SPECIALISTS. 

FIRST AID. 

SEX HYGIENE. 

STUDYING 

COMMUNITY 
HEALTH 
PROBLEMS 
AND METHODS 
OF IMPROVE- 
MENT. 

DAILY ORAL 
QUESTION- 
NAIRE ON 
HOME 
HYGIENE : 
USE OF 
TOOTH-BRUSH, 
COFFEE 
DRINKING, 
VENTILATION, 
ETC. 
HEALTH 
KNOWLEDGE, 
HEALTH 
IDEALS, 
HEALTH 
EFFICIENCY. 



"THE HYGIENE 
OP INSTRUC- 
TION." 

FATIGUE, 
OVER-WORK 
AND UNDER- 
WORK. 

THE TYPE OP 
BOOKS. 

THE HYGIENE 
OF SCHOOL 
SUBJECTS. 

INTEREST AND 
ATTENTION. 

INTER-RECI- 
TATION RE- 
CREATION. 

TRANSFORM- 
ING NEURAS- 
THENIC AND 
"CRANKY" 
TEACHERS. 

MO.TOR 
ASPECTS OF 
TEACHING. 

THE GOSPEL 
OP WORK. 

THE HYGIENE 
OP JOY IN 
SCHOOLS. 

PREVENTING 
PHYSICAL 
DEFECTS AND 
PATHOLOGICAL 
CONDITIONS. 

SCHOOL 
PROGRAMS. 

PART-TIME OR 
WHOLE-TIME. 

INFLUENCE 
OF VACA- 
TIONS AND 
HOLIDAYS. 

HEALTH IN- 
DIVIDUALITY. 

HYGIENIC 
EFFECTS OP 
DIFFERENT 
METHODS. 

THE TEACHER 
AS MEDICAL 
GUARDIAN. 



MEDICAL INSPECTION PLAN 297 

named: * play and playgrounds, selection of school sites 
and special phases of school architecture from the hygienic 
standpoint, pure water, school cleaning, gymnasiums, ven- 
tilation, heating and lighting, athletics, physical training, 
summer playgrounds, evening recreation centers, selection 
of textbooks for the teaching of hygiene, the print of books, 
problems of fatigue and school programs, home study, 
proper seating, feeding of the under-nourished, open-air 
and open-window schools, the work of school doctors, 
nurses, dentists, oculists, and the school clinics, co-operation 
with dispensaries, hospitals, infirmaries and private bodies 
desiring to aid school health work, and, finally, the educa- 
tion of the public along all lines of educational hygiene and 
the care of school children. 

B. The Director of Hygiene should be a doctor of 
educational hygiene, or a doctor of public health (D. P. 
H.) Lacking training colleges for such men as yet, a 
physician who is a specialist in children's diseases and who 
has made a special study of the science and practice of 
educational hygiene, at least of physical education, and has 
had successful experience in it, should (by competitive 
examination) be selected. A number of physicians, qualified 
fairly well by study and successful experience in school sys- 
tems, colleges, normal schools, Y, M. C. A.'s and children's 
hospitals and clinics, are at present available at salaries 
from $2,000 to $4,000 a year, and the demand will lead 
to an adequate future supply. Several cities now have 
such directors. After a brief search the writer has found 
twenty men qualified and available for such work. 

The health of the children of the schools and nation 
will not be adequately preserved and protected until such 
a definite organization and such health leaders are incor- 
porated in school systems. Efficient leadership furnishes 



*See elaboration of these phases in Hygiene and Physical Educa- 
tion, for June, 1909, in The Progressive Journal of Education for 
September, 1909, American Education for April 1912, Education for 
December, 1912, in School and Home Education for May, 1912, and in 
The Journal of Education for February 27, 1913. 



298 SCHOOL HEALTH ADMINISTRATION 

that scientific management, inspiration, and breath of life 
necessary in all successful social organization, and the school 
cannot afford longer to miss its advantages in the funda- 
mental field of health. 
C. Scientific Organization with Little Increased Expense. 

The expenditure for such a Supervisor of Hygiene, in 
cities that already are doing their duty to the children in 
the line of health, with school doctors, nurses and physical 
training teachers, frequently may require little or no addi- 
tion to the present school budget, the work being merely 
that of reorganization of the various health provisions 
which have, in various ways and for several years, been 
coming into the school systems. In all but the largest cities 
the director can take the place of one or more part-time 
physicians, and can also do the work of one or more super- 
visors, or teachers, of physical training in the elementary 
schools. Money can also be saved by having him direct the 
summer playground work which now costs a number of 
cities considerable sums, the school clinic or clinics when 
started, high and elementary school athletics, evening recre- 
ation, and a number of other savings which may go to 
make up his salary. The nurses, when so directed, may 
take the places of attendance officers in many cities and 
so save another considerable item. 

The present expenditures in these fields and the reorgan- 
ized expenditures have been given in preceding chapters 
and tables. Most cities have not yet caught up with the 
school health needs; but most cities of average size can 
secure such departments of hygiene for little over two to 
three per cent of current school expenditures. In many, 
the added expense will, as suggested, be inconsiderable. 

For further concreteness, the old and the new reorgan- 
ized expenditures, for a fairly typical city already possess- 
ing the elements of such a department, are here given. 
This city has a population of about 50,000; there are 15 
schools, a public school average enrollment of 6,000 pupils; 
and annual current expenditures amounting to about 
$250,000. 



MEDICAL INSPECTION PLAN 299 

OLD, UNCORRELATED SYSTEM 

2 high school teachers of physical training $2,200 

2 elementary school teachers of physical training 1,800 

6 physicians, two one-hour school visits weekly, at $300 i,8oo 

3 school nurses, 44 hours a week, at $750, ten months 2,250 

Total $8,050 

RE-ORGANIZED, DIRECTED SYSTEM 

1 supervisor of hygiene, full time, 11 months $3,000 

2 high school teachers of physical education 2,200 

I assistant physician, two hours a day, ten hours a week 400 

3 school nurses, 44 hours a week, 2 at $825, i at $750 2,400 

Total $8,000 

Here we have the new organized and directed system 
at less than the original cost. There remain fifty dollars 
toward more efficient records and blank forms. We have 
deducted nothing for saved expenditures for attendance offi- 
cers, playground direction, etc., nothing but five unneces- 
sary part-time physicians and the two elementary teachers 
of physical training. Where the latter officials are paid 
less in the old system and the supervisor $2,500 instead 
of $3,000, there is another balancing of expenditures. The 
point is that the added expense need not be great. 

The third nurse may not be added the first year, which 
would give a further reduction of $750. Perhaps scientific 
management may make her permanently unnecessary in 
many cities. 

The supervisor can, with the daily help of one of the 
two or three nurses, for two hours a day, examine the same 
number of children as the assistant physician, 3,000; and 
he can call the teachers together by grades and teach them 
how to carry on the physical-training work at the schools; 
and can take part of each day in supervising their work. 

The assistant physician is paid $100 more a month, and 
gives two full hours in one school daily. With the assist- 
ance of one of the nurses he can examine during the school 
year the other half of the school population (3,000 pupils), 
and can help make such inspections as are necessary. The 
third nurse, if employed, is left free for individual and 



300 SCHOOL HEALTH ADMINISTRATION 

class-room inspections and for follow-up work. Neither the 
teachers nor the physicians are bothered with vision and 
hearing tests, the nurses making them; and practically all 
clerical work connected with medical supervision will also 
be done by the latter. The physicians will be free for tech- 
nical medical work, and the teachers will be less interrupted. 

Two of the nurses are paid for an extra month in the 
summer, one for July and one for August, to follow-up 
cases not cured at the end of the school year and for neces- 
sary inspection of children at summer schools and play- 
grounds. Some of the most valuable work now being done 
by nurses is accomplished in these summer months; and 
the number of skin, parasitic, and infectious ailments is 
very much less at the opening of the next school year. 

The two high school teachers of physical training, one 
a man and the other a woman, are left at perhaps the same 
salaries ($1,300 and $900). 

The supervisor of hygiene gives his entire time to the 
work, not for ten but for eleven months. If he obtains a 
thoroughly good assistant school-physician, the salary of 
the latter may be raised from $400 to $500 or more, but 
not sufficient to make possible the employment of another 
nurse at the same sum, perhaps. It may be well to employ 
a woman physician as part-time medical examiner so she 
may better examine the high school girls. 

The trials and tribulations of the superintendent in 
trying to get regular and responsible work from part-time 
physicians and in attempting to direct medical work without 
medical knowledge, are now at an end. He has a small, 
compact and almost entirely full-time force. These are 
essentials. The entire part-time element may yet be elim- 
inated, but it will mean salaries from $1,500 to $2,000, at 
least, for full-time assistant physicians. 

Later developments of the system can be made, how- 
ever, after intelligent study and experience. If another 
physician is desired he may be obtained, and if, as the city 
grows, an assistant in physical education for the elementary 
schools is found necessary, the addition can be made. But 



MEDICAL INSPECTION PLAN 301 

these additions are intelligent choices by an expert in edu- 
cational hygiene, after reasonable investigation. We at- 
tempt to give here only minimum essentials and suggestions 
for beginning or reorganizing the work.* 

For the largest cities, such a health reorganization can 
easily be made, and it is practically possible for many cities 



*At the recent International Congress on School Hygiene at Buffalo 
the writer was given practically the following facts by a member of a 
board of education of a typical New England city (about 9,000 pupils) 
with a request for a plan of efficient reorganization: 

PRESENT "INEFFICIENT" SYSTEM 

12 part-time physicians at $500 $6,000 

nurses 000 

2 truant officers 2,500 

1 elementary physical training teacher i,000 

I summer director of playgrounds 150 

$9,650 
This system, recognized by the board of education as inefficient 
and not getting results, is a finely devised machine for getting little more 
than a collection of pathological statistics of school population. The time 
the physicians spend in the schools is unknown ; and they have no super- 
vision nor nurses to follow-up cases and get treatments and cures. 
There are no public dispensaries for free treatment of children, and a 
large share of the population is too poor to pay $20 for an adenoid 
operation, for example, or to provide regular daily or weekly treatment 
for favus, ringworm, discharging ear, and other ailments. There is enough 
money being spent, however, to get efficient results in this field. Leaving 
the high school directors of physical education in their places at the 
same salaries, we gave for a beginning the following: 

PLAN OF REORGANIZATION 

1 supervisor of hygiene, a physician-physical-educator $2,500 

6 school nurses, 4 at $700, 2 at $770 4.440 

2 part-time physicians, two hours daily, at $500 i,000 

I school clinic, with dental, surgical, and medical divisions 1,000 

I school dentist, with staff of voluntary dentists 500 

New blank forms for records and reports 2I0 

$9,650 
Here we have a vastly more efficient system at the same expendi- 
ture of money; we have skilled leadership and supervision; we have a 
plan which unifies all school health agencies; and we have the emphasis 
where it belongs, on prevention and cures. Necessary changes can be 
made after adequate investigation by the hygiene supervisor and super- 
intendent of schools. 



302 SCHOOL HEALTH ADMINISTRATION 

almost as small as eight or ten thousand population. Sev- 
eral towns may even go together and employ such an expert, 
as superintendents are now employed in several states. And 
even rural districts may unite in the same way for the 
expert services of an educational hygienist and several 
nurses. The great need is for health experts and for health 
leadership. The people will respond and act along the 
best health lines when the health knowledge, now the pos- 
session of the few, is made the possession of the many. 
We have suggested here a possible channel for such general 
health enlightenment. The far-reaching influence of such 
school health leadership on national health and vitality can 
as yet hardly be imagined. 
D. Other Plans for the School Medical Service 

Disregarding as ineffective the physician-alone plan for 
school medical work, we have two principal alternatives 
for serious consideration: the physician-and-nurse plan, al- 
ready suggested, and the nurse-alone plan. For both there 
is the need of a supervising director of hygiene, unless the 
superintendent of a small city is exceptionally well qualified 
medically and has time to devote to the work. We need 
supervisors of hygiene as much or more than we need super- 
visors of music, drawing, and such subjects. For both plans 
we may have either examinations with inspection or only 
inspection alone. We shall take the stand that routine exam- 
inations, annually, are important as well as inspections. In 
the nurse-alone plan the routine inspections, with the use of 
individual cumulative health record cards, can, at first, take 
the place of complete medical examinations, by simply 
adding the vision and hearing tests. 

The nurse-alone plan is, in general, far superior to the 
physician-alone plan, for a number of reasons, chief of 
which is that the former gets treatments and cures for a 
large percentage of the cases, while the latter procures 
treatment and cure for but five or six to twenty per cent 
of the cases. Furthermore, the nurses can find most of the 
cases of all kinds, and can inspect satisfactorily, as proved 
in New York, for infectious diseases, especially when under 



MEDICAL INSPECTION PLAN 303 

supervision (September, 191 1, Report of Bureau of Muni- 
cipal Research). Cities as small as Canton, Mass., with 
less than five thousand population, and as large as Oakland, 
Cal., with nearly two hundred thousand, get good work with 
only nurses, under supervision. (Reports and letters of 
Dr. Arthur T. Cabot and of Dr. N. K. Foster, respectively.) 
Newark with 38 doctors and 8 nurses is reversing these 
figures by exchanging two doctors for each added nurse. 
Only five or six doctors will be kept as district supervisors 
of the nurses. With the general supervisor as before this 
will greatly increase the eificlency for the money expended. 
Further, the physicians can work but part-time while nurses 
devote their entire time to the work. The physicians are 
irregular and difficult to control in large numbers, while the 
nurses, with practically no serious competing interests, are 
easily directed. And, finally, they are less than half, and 
frequently only one-fifth as costly, hour for hour, and for 
the year, as physicians. The tables given in former chap- 
ters show even greater disproportions of cost in a number 
of cities, when the annual number of daily visits, and num- 
ber of hours each, are taken into consideration. Good, 
regular physicians, furthermore, can spare little more than 
two hours a day regularly and punctually from their prac- 
tice; and physicians for longer periods must be paid too 
much and cannot well stand the strain and monotony of 
long-continued examination or inspection. Diminishing re- 
turns, with the larger salaries for full-time physicians, bring 
in the school nurse often much more efficient hour for hour 
than such physicians as can be obtained. That the 
nurses need training, before and while in service, and that 
they must have competent supervision is immediately appar- 
ent. The plan here outlined, however, places the emphasis 
upon the nurse and the physician, the physician-nurse plan. 
Getting full-time work from all school health officials re- 
mains a nice problem for careful study and local adjustment. 
The first thing is to get the hygiene supervisor, next the 
nurses, and finally part or full-time physicians. A very small 
city unable to obtain, with others even, a supervisor should 



304 SCHOOL HEALTH ADMINISTRATION 

start with a nurse rather than with part time physicians if 
possible. If only a physician is employed the principal and 
teachers must do the follow-up work. In either case the 
record and report forms herein given may be used. 
E. Where to Obtain School Nurses. 

As with all other forms of public service, the success 
of medical and health work depends very largely upon the 
character of the persons chosen to carry it on. The greatest 
weakness of our school systems at the present time is due 
to the fact that our teachers are quite generally young 
women novices with a teaching tenure of three to five years 
only and very largely ignorant of and inexperienced in the 
real life of the community and nation about them. Edu- 
cational readjustment must wait upon the improvement of 
the character of the teaching force. With even the best 
of supervision and the most scientific plans of management 
the health service likewise can remain palsied, feeble and 
inefficient. 

After deciding to obtain officials for the school health 
work, therefore, the practical problem becomes one of ob- 
taining high-class health agents. For nurses, we must as 
yet depend very largely upon the various training schools 
for visiting nurses, and the visiting nurses' associations. 
The Department^ of Nursing and Health, under the direction 
of Miss M. A. Nutting, R.N., at Teachers College, Colum- 
bia University, in New York City, is at present the only 
institution in the country which gives instruction and train- 
ing for school nurses, and the number who can be supplied 
is at present very small. This is the first source I should 
recommend. 

Miss E. P. Crandall, R.N., Executive Secretary of the 
National Organization for Public Health Nursing, 52 East 
Thirty-fourth street. New York City, and Miss E. L. Foley, 
R. N., Superintendent of the Visiting Nurse Association, 
104 South Michigan avenue, Chicago, may also be de- 
pended upon to advise school systems of graduate nurses 
who are specially qualified for and looking toward public 
school work. Miss Fannie F. Clement, 713 Union Trust 



MEDICAL INSPECTION PLAN 305 

Building, Washington, D. C, can give valuable informa- 
tion regarding the Red Cross Rural Nursing Service and 
persons available as school nurses. The Boston District 
Nurses Association in affiliation with the Boston School for 
Social Workers, as well as the Cleveland Visiting Nurses 
Association in affiliation with Western Reserve University, 
and, finally, Phipps Institute of Philadelphia are also in 
touch with most nurses in the country. 

The writer will be pleased to send the names of any 
persons known as qualified either as hygiene supervisors 
or as school nurses to responsible persons without charge 
to either party. Like Albany, N. Y., a city may find in its 
midst a man qualified both as a physician and a physical 
educator for such work and good nurses amenable to train- 
ing in the school service. 

II. THE DIVISIONS OF MEDICAL SUPERVISION 

The various phases or divisions of the work of medical 
supervision * in this plan and, for the most part, but largely 
unrecognized, in the best systems now in vogue, are about 
as follows : 

A. Preliminary clinic, for instruction and standardization. 

B. Inspections. 

1. Pupil Inspections. 

a. September roow-inspection of all pupils by 
doctors and nurses. 

b. Occasional room-inspections of classes of chil- 
dren, by nurses. 

c. Individual inspection, by teachers, nurses, and 
doctors. 

2. Environmental Inspections. 

a. Home hygiene inspection, during home visits 
of nurses. 

b. Sanitary inspections of the school premises, 
by any delegated and competent officer. 

C. Examinations, complete physical, annually for all pupils. 



*The term will probably remain medical inspection, even if it is a 
misnomer in good systems. 



3o6 SCHOOL HEALTH ADMINISTRATION 

1. Scholastic: vision and hearing examinations, and per- 

haps others, by the nurses. 

2. Medical: only those technical phases which the nurses 

cannot do well, if any, by doctors. 

3. Anthropological: measurements of height, weight, 

chest-expansion and the like, only if required. Of 
doubtful value. 

4. Work Certificate : will probably not be needed in well 

conducted systems. 

D. Treatment, Cure and Correction. 

1. By home and family physicians, dentists, or oculists. 

2. By school nurses. 

3. By dispensaries or other free clinics. 

4. By public school clinic, with various divisions. 

E, Prevention. 

By looking for causes, co-operating with other divisions 
of educational hygiene, and other public and private 
health agencies, and by placing the emphasis upon 
preventive rather than merely curative agencies. 
How to carry on efficiently and economically these dif- 
ferent phases of the work will be the problem of this 
chapter.* 

A. The Preliminary Standardization Clinic 

In the typical city for which the reorganized expendi- 
tures were given, with a proportion of little over three 
per cent of current school expenditures for the entire 
department, including medical inspection, we have two phy- 
sicians and three nurses for six thousand pupils from kinder- 
garten through high school, three thousand for each phy- 
sician (one the director), and two thousand for each nurse. 
For a city of twelve thousand children we should have, of 
course, twice as many nurses and three assistant physicians. 
But no matter how large or how small the department may 
be, even one physician and one nurse, there should be, when 
they begin to work together, and, if several, at the begin- 



*For relative complete "Outlines of Educational Hygiene," empha- 
sizing medical supervision, by the writer, see Education for December, 
1912. 



MEDICAL INSPECTION PLAN 307 

ning of each year or oftener, a meeting at which children 
are examined or inspected, or both, and standards for refer- 
ring cases to parents, for exclusions, for readmissions, for 
best methods of doing the work, and the like, are discussed. 
Teachers and principals may be present at such meetings, 
and all may take a hand In coming to some common agree- 
ment, without which there will, In Isolation, develop the 
greatest irregularity among different workers and frequent 
injustice to children and parents through conflicting stand- 
ards and methods. 

This is also the opportunity for the supervisor to outline 
the work of the year, and to get suggestions from all con- 
cerned as to its improvement. It is a time for inspiration 
and education. All need them. Such clinics can be held at 
one or more of the several schools, if desired, or at teach- 
ers' meetings, for the purpose of giving the teachers neces- 
sary elements of child-study of a medical character, which 
probably never appeared in any course In their professional 
preparation. 

No city known by the writer now employs this means 
for making efficient medical supervision, and he hopes for 
Its speedy experimental testing. Besides these will come, 
of course, monthly or semi-monthly department meetings 
which are now quite common in good systems. 

B. Inspections 

I. PUPIL INSPECTIONS 

a. September Class-room Inspections. — Since this plan 
of administration gives the physician as many pupils as he 
can examine in the entire year, beginning In September 
about the third week, and taking pupils In the same order 
each year, we must provide what many cities have been 
driven to by hard experience, namely, a preliminary, com- 
plete, routine, classroom inspection of all pupils. With 
3,000 pupils, each pair of nurses and physicians will have 
about 75 rooms, counting 40 pupils to a room. By requir- 
ing the part-time physicians to spend three hours a day In 
this first general inspection, and with the nurses all at the 



3o8 SCHOOL HEALTH ADMINISTRATION 

same work, counting a classroom, after practice, for each 
half-hour, and records made, where two work together, 
we can see that the entire inspection can be made in about 
two weeks. In the case of the two doctors and three nurses, 
one nurse would have to work alone at such inspections; 
and in the afternoons when two of the nurses worked 
together in each room another would be left to work alone, 
as she must later in occasional room inspections. In fact, 
we can be sure of over 20 rooms inspected a day from 
the small force of five above mentioned, which for the total 
of probably 150 rooms in the city, would make about eight 
days. So two weeks would probably be ample with such 
a system. 

Some doctors lay claim to 250 pupils room-inspected an 
hour, but these are only very partial inspections, for signs 
of parasitic or infectious disorders. This first general rou- 
tine inspection would make a fair substitute for an exam- 
ination, especially if there were any careful attention given 
to vision and hearing. It is a general inspection of the 
child for any serious defects, ailments or conditions which 
should receive early treatment and care. No vision or 
hearing tests, as such, are made, but all obvious cases, like 
strabismus (cross-eye), or inflamed eyes from eye-strain, 
may be recorded and referred with instructions. 

The principal ailments found will probably be minor 
skin ailments of a filthy or infectious character, although 
most ailments will be represented. If there have been 
nurse-inspections during the summer, fewer cases will be 
found, but there are always sufficient numbers to warrant 
rigorous measures for nipping their spread in the bud. 

THE METHOD OF CLASSROOM INSPECTIONS 

The central instrument in all medical supervision (in- 
spection) is the individual, cumulative health record card 
of each pupil. On it is recorded the health history of the 
child during his school years, and in some cases for the 
years previous to his entering school. The development 
of the science of educational hygiene and the practical con- 



MEDICAL INSPECTION PLAN 309 

trol of health matters must depend very much upon the 
quality of such individual health histories. Scientific con- 
trol of living conditions of children, or of any other phe- 
nomena, rests upon the basis of accurate and carefully se- 
lected facts. With this principle in mind, and the prog- 
ress of child and of educational hygiene as a much-to-be- 
desired practical necessity, by what standards shall we judge 
such health record cards? Tentative standards used by the 
author are as follows : 

a. The record must be a separate filing card, not a page 

In a book, nor a loose sheet of paper. The great- 
est device, or Instrument, for inductive thinking yet 
Invented is the well-devised card-index system. Pro- 
fessor Giddlngs well says that Jevons' invention, of 
a "deductive logic machine," Is but a useless toy com- 
pared with the modern ''''inductive logic machine," 
the card Index. 

b. This card must go with the child from room to 
room, from school to school, and from city to city 
throughout his school life. The cities that are using 
cards good for one year only are wasting money and 
not getting the cumulative history which can al- 
ways be before teacher, nurse and physician when 
they study the child from the standpoint of his health. 

c. The record must, as nearly as possible, contain each 

child's entire health history, especially of serious dis- 
eases, injuries, or defects, winter or summer, and the 
results of treatments, and dates of cures. 

d. The records must be made by both physicians and 
nurses, and their records distinguished, say black Ink 
for the physician and red for nurse. With our plan 
most of the records will be in red Ink. Examina- 
tions by specialists, dentists, aurlsts, or oculists can 
also be recorded on the same card. 

e. Arrangement must be made for recording the chang- 

ing addresses, rooms, and schools of pupils. The 
telephone number of the parents Is desirable wher- 
ever it can be obtained. 



3IO SCHOOL HEALTH ADMINISTRATION 

f. The results of both examinations and inspections are 

to be recorded. 

g. The card must either have the diseases and defects 

most often found and most to be emphasized printed 
thereon, or be used in constant connection with a de- 
tailed and numbered list of such ailments (code), for 
which only the code numbers need be used, or the 
code number accompanied by an abbreviation for a 
special and unusual ailment. The Cleveland card, 
most carefully drawn up, has a code entirely too brief 
printed upon it, and has no satisfactory arrangement 
for recording treatments and cures. The New York 
city and the cards devised by Burks, Hoag, and Cor- 
nell have similar or other serious defects. 

h. The card must leave space with each year's record 
for writing in any general recommendations, sugges- 
tions to teachers, and the like, which are so individ- 
ual that they cannot be reduced to code numbers or 
other signs. Real health records have been prac- 
tically prevented by attempting to reduce the whole 
matter to making checks opposite a few ailments. 

i. The signs, or symbols, used to save space and time 
and for a degree of privacy, if desired, should very 
probably be printed on each card. The need of keep- 
ing the children in entire ignorance of their ailments 
does not appeal to the author's experience. Democ- 
racy is better. Some of these signs, to be found on 
the card offered herewith and devised for tentative 
testing by the author, may well be : — 

X — A cross, for "needs treatment, and should be re- 
ferred to parents." 

O — a circle around this cross, to be made by the nurse 
when the ailment is cured. 

O — a circle in the second space, to the right of the X, 
showing that the ailment has not been cured, but 
has been improved. No circles will show that the 
case has not been cured, or improved, or the child 
has moved away, without his card, or the family 




311 



312 SCHOOL HEALTH ADMINISTRATION 

has refused treatment, or the family physician has 
called the case "negative," that is, too minor an ail- 
ment for treatment or operation. A diagonal line 
may be drawn through admitted negative cases and 
deducted from the number previously reported. 

I — a vertical line, to the right of the X or O, showing 
in red that the nurse, janitress, or school clinic has 
treated the case, and in black that some other "out- 
side" agency has made a treatment or series of 
treatments. Red lines over near the space for re- 
marks on the same horizontal line, or to the left of 
this space if desired, may be used to indicate times 
the nurse has taken the child to dispensary, family 
physician, or clinic. Home hygiene visits, or sim- 
ply home visits, may be similarly recorded under 
that heading. 

P — in the space for the date of the annual medical ex- 
amination at the top will mean that the parent or 
guardian of the child has been present at that ex- 
amination. This is important, for better results fre- 
quently follow if parents are present, and the records 
should show it. In general, however, parents attend 
much better with their children school clinics. 

V — a check, in place of an X, will show that the ailment 
is too minor to be referred for treatment. Few such 
checks will be required. Certain incipient ailments 
must, perhaps, be noticed in this way, however. The 
discretion is with the supervisor or other officers. 
Too many very minor cases are now being recorded 
in many cities. Be conservative. Check cases need 
not be reported. 

E — will show that the child has been excluded for the 
ailment marked X. 

R — will show that the child has been readmitted. The 
teachers will keep a record of the time lost by all 
exclusion or illness absence and record it at the bot- 
tom for each term each year. 

Other signs can be devised for other meanings. 



MEDICAL INSPECTION PLAN 313 

In the space for remarks, the medical officials will write 
such facts or suggestions as cannot be given by the system 
of signs. 

The back of card number one is not here reproduced. 
Four horizontal spaces at the top may be left for: the pupil's 
name and addresses, the history of measles, scarlet fever, 
diphtheria, whooping cough, chicken pox, vaccination and 
other ailments with spaces for checking or writing in the 
dates, the nationality if desired, and spaces for changing 
room numbers or letters. The fourth space may be used for 
the symbols given on the face, and for others desired. Below 
the headings, the card may be made up the same as on the 
face, for three years. 

To the right of these, I have a section for Home 
Hygiene Inspection, printed in the space for dates of ex- 
aminations and presence of parents, somewhat similar to 
the Cleveland and the Hoag cards (see Health Index of 
Children). Beneath this heading on the 25 lines I have 
printed (with five vertical spaces to the right) the follow- 
ing: Grade, Date, Children in school — Boys, Girls, Num- 
ber of rooms, Number of bed-rooms. Number of beds, 
Bath tub?. Ventilation, G — F — B (good, fair, or bad), 
Lighting, G — F — B, Cleanliness, G — F — B, Number of 
families using closet, Financ. (for financial condition), 
G — F — B, Nourishment, G — F — B, Children's hours of 
sleep. Home study opportunity. Mother, Father, Sisters, 
Brothers, Boarders, Co-operation with the school (i. e., 
how well they respond to the nurse's and teachers' efforts) 
and spaces for writing in other data. This matter is, of 
course, unnecessary on card number two. 

FURTHER SUGGESTIONS FOR USING THE RECORD CARD 

It is relatively unsatisfactory to attempt to place under 
even twenty-four headings the ailments which physician and 
nurse must look for and record. One line may be over- 
crowded while there are left many lines unused, and ailments 
not printed thereon may be found. To overcome this difli- 
culty, a space over a half-inch wide has been left for writ- 
ing in the name, abbreviation, or code number found in the 



314 SCHOOL HEALTH ADMINISTRATION 

weekly report for fifty-four ailments and groups of ailments, 
the term "ailment" referring to all the health disorders of 
childhood, including physical defects. 

Still further to overcome this difficulty, all names of ail- 
ments may well be left of the card, the spaces mentioned 
widened for each year entirely to take up the space where 
names for ailments are printed, and only code numbers used 
in the first narrow column for ailments each year. The fig- 
ure (code number) there would indicate that the ailment 
had been found, and the signs above mentioned would fol- 
low as before, on the same horizontal line. Or the card 
may be entirely reorganized on a freer basis, giving one like 
the second type here reproduced. 

CARD NUMBER TWO 

The principal disadvantages of the first card are ( i ) 
that it is impossible to write on it the entire series of efforts 
which may be necessary to get cured one case, resulting 
in the overcrowding of one line or two and leaving blank 
a large part of the card opposite ailments from which the 
child does not suffer, (2) that since the names of ailments 
must be general and in only 24 divisions, the code num- 
bers and the abbreviations or full names of the specific 
ailments must be written out anyway. Even with a card 
long enough vertically to make possible the printing of the 
54 classes of ailments, it would still be necessary to write 
in the specific name (say, for minor skin diseases). An- 
other weakness is the home hygiene inspection division 
separated from the ailment and time of inspection or fol- 
lowing up of the case. Yet this card has been declared, 
by a committee studying the record systems of over seventy 
cities, superior to all in use. Burks' interesting card or 
slip (Health and the School, page 179) has the same and 
other defects, his system being devised more for such large 
cities as Philadelphia, with large central office forces. 

Our card number two of which the face, partially filled 
in, is given, has been evolved out of all these defects and 
difficulties. It gives freedom to record essential data not 
easily placed in a system of rigid symbols, economizes 









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3i6 SCHOOL HEALTH ADMINISTRATION 

space, shows immediately what ailments have been found 
and what has been done with them, records both inspec- 
tions and examinations and all dates, and makes possible 
adequate reporting of follow-up and home hygiene work. 
Most of it will be filled in (with red ink) by the nurses. 
Another space may be used for printing in other symbols 
while the number of lines for the second year may be de- 
creased to four. The card may be arranged for ten or 
more years of school life, five or six years on each side. 
The heading for the back of card i should also be used 
for this card. No home hygiene space need be arranged 
as this has been provided for each year. For special cases, 
the five lines for the first year may be used for a careful 
health history. 

The card will, of course, be used with the classification 
and nomenclature of ailments in view as they are printed 
on the weekly report. 

Interpreted, some of the written-in record has the 
following meaning: For the first year, 1910-11, enlarged 
tonsils and adenoids were found at the time of the first 
(September) routine inspection of all children. We see at 
once that they were found and cured. They were referred 
September the tenth, but the family did not respond well; 
so the mother, a poor widow, was visited on the fifteenth. 
The latter gave the nurse permission to take the child to 
the dispensary where her adenoids and tonsils were removed 
on the twenty-second. The nurse should have seen the 
child every day or two immediately after the operation, 
but probably wisely depended upon a responsible teacher 
to send her for inspection if her wounds did not heal well. 
On the second of October, however, she did inspect the 
child, then seven years of age, and found her apparently 
cured. She could not then state whether the adenoids would 
grow again' but apparently the child was developing satis- 
factory nasal breathing, in place of the former mouth 
breathing. 

For some reason, the child was given her annual exam- 
ination on September the fourteenth, which resulted in 



MEDICAL INSPECTION PLAN 317 

the finding of pediculosis and nits, but her vision was good 
with her glasses on, and her hearing was satisfactory. The 
subject of pediculosis was brought up at the first home 
visit recorded above and the mother promised treatment 
which she carried out, with improved condition, and twice 
afterward following notice by the nurse. The examination 
showed the ailment; it was improved; two inspections 
showed the ailment later, and it was again improved. The 
teacher had evidently sent the child to the nurse for the 
inspections or the nurse had kept after the case and called 
the child out those two times. 

The next year, 1911-12, the child was again mouth- 
breathing and the adenoids had probably grown again but 
the nurse took the child to the dispensary and an operation 
was spared by the dilation of the child's nostrils. This 
should have been done, and perhaps continued by the nurse, 
during the first year. The other items are probably easily 
read, V equals home visit; T equals teeth; Tr equals 
treated or treatment; H equals board of health. Any 
added symbols should be uniform for each city, at least. 

Where a child presents unusual need for treatments, the 
spaces for two or more years may be used for recording 
them. A five by eight card should be standard since the 
smaller ones unnecessarily cramp the work. Our card num- 
ber two has been reduced for book purposes to a seven-inch 
length. We have not shown a record of days lost by illness 
nor a very wide range of home hygiene reporting, although 
the form admits of it. 

Either of these cards, printed on both sides, and contain- 
ing the names of the places using them, and the other forms 
given later, will be sold in quantities by the publishing de- 
partment of Teachers College, Columbia University, New 
York. The appearance of the cards will be improved by 
printing in all words. 

Where a child spends more than eight years in the 
elementary school system or enters the high school, another 
card may be clipped to the original card. In fact, for very 
serious and prolonged cases, the annual spaces with dates 



3i8 SCHOOL HEALTH ADMINISTRATION 

above may be turned into term spaces and an additional 
card added earlier than the ninth year of school life. 
Whether cards should begin with the kindergarten chil- 
dren, may rest with the medical director, and superintendent 
of schools. They probably should' with the exception of 
the vision test perhaps. Provision for changing addresses 
may be made by furnishing gummed strips of paper the size 
of the address space. This is a compromise plan to save 
space. On the second card the addresses may be written 
in the first space to the right of the symbol spaces for each 
year after the spaces at the top have been used. 

Thus we have offered two record cards instead of one 
for use, adaptation, and criticism. The first has many ad- 
vantages, but limits seriously the amount of space for re- 
cording the facts regarding any one ailment; the second is 
simpler, and gives plenty of space for recording the nature 
and treatment of any ailment. It also affords more chances 
for error in using and interpreting the code numbers, per- 
haps. The second will probably win out after trial. 

These cards (5 by 8 inches in size) may be kept in 
the teachers' classrooms in small, durable filing cases, such 
as are furnished in New Bedford, Mass. It is probably 
not wise to keep all the cards together in the medical in- 
spection room, for several reasons. At each inspection or 
examination the child takes his card in a clean piece of 
paper, or one child carries several of the cards, or some 
other person, nurse, janitress or principal's clerk, collects 
them, and takes them to the health officers' room. For 
room inspections, of course, the cards need not be taken out 
of the rooms, except as the nurse uses them for making 
her records and reports. If the health histories are to be 
used and if teachers are to be educated in health watchful- 
ness, the cards must be kept before them in their rooms. 

The "parasitic ailments" are favus, ringworm of body 
or scalp, pediculosis or vermin, scabies, and one or two 
others seldom if ever found. Where a child has two such 
ailments, use the space for infectious ailments or for skin 
ailments in the section above, writing in the name or code 



MEDICAL INSPECTION PLAN 319 

number on the right. (No such trouble will arise with the 
second card presented.) Physical defects are placed at the 
top as in the weekly reports and the tentative standard 
classification of ailments. 

THE METHOD OF THE SEPTEMBER ROOM-INSPECTION 

Coming back to the September room-inspection with an 
understanding of the individual health record cards, let us 
briefly suggest a workable method. In one of the first 
plans of this kind drafted by the author in 1908, the 
doctor and nurse were to go to separate rooms and the 
teachers were to make the records on the cards for them. 
If teachers could do this well or if it were thought valuable 
enough training to take the time to teach them, this would 
be satisfactory; since the general room-inspection at any 
time could be done about twice as rapidly as when the 
nurse and physician work together. Teachers, of course, 
need such training and knowledge of both the cards and 
the children. 

However, the nurse frequently needs the doctor's sup- 
posedly better knowledge and advice, and she can record 
the matter on the cards very much better than teachers. 
Doctors who have tried both methods say that the rapidity 
and ease with which the nurse and doctor working as a 
team can do room-inspection eliminate all other methods. 
The nurse, however, cannot see each case so well when 
she is sitting at a desk busily copying signs; and most values 
might be gained by having the teacher make the records 
with the nurse free to watch both her and the doctor. 
This probably deserves test. It serves to educate the 
teacher, but leaves the class-room of children to some ex- 
tent, undirected, although a strong teacher can use the situa- 
tion as she thinks best, either for continued study by the 
pupils or for watching the work proceed, and getting an 
intelligent attitude toward health matters. This is again a 
matter to be tested. The outcome will probably be that the 
nurse will record and learn to see the cases too. 

Near the back of the room on the left side of the 



320 SCHOOL HEALTH ADMINISTRATION 

pupils will probably be found good light. Here the doctor 
can take his stand and the pupils by rows of five or six, or 
boys first and then girls, or in any other convenient way, 
can file pass him. He may be seated, since it is well, with 
certain exceptions, to start with the pupils in the lowest 
grades in both general inspection and in examinations. 

The nurse, let us say, sits at a desk nearby and records 
the doctor's findings and the disposition of each case. The 
physician gives a quick, accurate glance at hair, scalp, ears, 
eyes and eyelids, face, nose, mouth, teeth, tonsils and throat, 
hands and skin, and quickly sizes up the general condi- 
tion of the pupil. The doctor does not touch the pupil 
but has each child open the mouth, show the hands, pull 
down the eyelids, perhaps, and, in the case of girls, lift 
up the back hair. Wooden tongue depressors are used for 
the mouth examination, and no depressor is to be used more 
than once. Where plant tag-sticks are used for depressors 
each one may be broken in two and used for two pupils. 
With increasing skill, all the pupils of a room can be in- 
spected in a very short time, less than a half hour, and aver- 
aging, perhaps, two pupils to a minute. 

The standard for the selection of cases for record can 
be seen in the following question which the doctor must 
ask himself: May this child remain in the school without 
injury to himself or to others, and is this ailment one which 
should have immediate care and treatment, and one about 
which the parent should be informed? If, in his judgment, 
and probably with the advice of the nurse, he concludes 
that it is a sufficiently urgent case of any kind, he gives the 
nurse the code number of the ailment from the printed code 
before him, and indicates what shall be done with the case. 
If he is in some doubt, the child is asked to take his seat 
or pass elsewhere until after the other pupils are inspected, 
and may then be taken into the hall or health room for 
further inspection. In Newark, N. J,, at most room-inspec- 
tions the pupils go singly into the hall where they are in- 
spected by the doctor, the nurse, or the two together. This 
plan has its advantages. 



MEDICAL INSPECTION PLAN 3^1 

The doctor should be conservative and practical in his 
iudgments. Most minor uninfectious cases may wait tor 
the routine examination when the parent may be present. 
Further standardization can come with experience, super- 
vision and standardization clinics. 

EXCLUSIONS 

Doctors and nurses must also be very careful and con- 
servative about the exclusion of pupils from school. On 
he average, such exclusions last, for all -Iments neady 
two or three weeks. Some are unnecessarily excluded for 
months. Most of the parasitic ailment cases -^ ■-™;;; 
in school with adequate treatment and control. Where an 
epidemic of infectious disease is imminent less suspicious 
cases may be excluded and throat cultures '^^en but con- 
servative judgment is not even here amiss_ The nu e 
should take cultures in every case of sore throat. These 
cultures must be tested and the children readmitted if nega- 
tive (i. e., if the Klebs-Loeffler baccilli are not found) as 

"° ChddCnISuiring exclusion may be given an exclusion 
slip at the end of the inspection of that room or imme- 
diately, if desired. The principal of the school may have 
such children referred to him, and may mail or send the 
slip to the parents from his office, besides sending an oral 
message by the children. Or, the telephone may be used^ 
The teacher should be notified of the exclusion and of the 
date fixed for the child's return to school. This may be 
written on the card protector. . r .■ 

Exclusions may be made for the following infectious 
ailments: diplheria, or sore throat or tons,ht,s possibly 
pointing to infection, scarlet fever, whoopng-cougk cincken 
po.. measles, mumps, traehoma, or any other possibly acute 
infectious disease, and such parasitic and minor infectious 
ailments as may be adequately treated over night if strongly 
called to the parents' attention. Montclair and some other 
cities have such cases treated in the school by the nurse or 
janitress, thus saving very much absence. Parents are tried 



322 SCHOOL HEALTH ADMINISTRATION 

first, and then, if the home does not adequately eradicate the 
ailment, permission is gained for the school treatment. 
Legal compulsion may be required, and should be used with- 
out fear or favor for the "filth" disorders. 

The nurse may make out the exclusion slip which should 
be simple, dignified and adequately instructive. If the back 
can be used for health advice, the chance should not be 
missed. The seal of the city printed on each as is done in 
the state forms of Massachusetts and certain cities, will ap- 
peal in the right way to many parents. The following 
exclusion form has several advantages in the way of 
economy : 

MEDICAL SUPERVISION OF 
SCHOOLS 

Montclair, New Jersey. 

Date , 191. . 

School Room, Grade 

Pupil's name 



EXCLUSION RECORD 

No 

Date , 191. . 

School Room 



Pupil 

Address , 

Cause of Exclusion: 



Readmitted, 



School days lost. . . 



191, 



Home address 

The above named pupil is hereby or- 
dered to discontinue attendance at 
school temporarily for the following 
reasons: 



School Nurse, M.D. 
(Hand to pupil excluded.) 

over. 



This entire form need not be more than six inches long 
and two and a half inches wide. 

On the back of the long part, not the stub, should be 
printed these and any other directions, general advice, or 
short article from city or state laws: 



The ailment mentioned on the other side of this notice is 
infectious (contagious), and liable to be transmitted, or "given," 



MEDICAL INSPECTION PLAN 323 

to other children. The child should receive prompt treatment 
by a physician or the school nurse, and should return to school 

, 191 .. , for inspection by the 

school physician or nurse. If found free from infection he may 
then resume attendance at school. 

Every reasonable effort should be made to give each child 
the full benefit of every possible day of school attendance. 

A DUPLICATE BOOK FOR DOCTOR AND NURSE 

This form, separable from its stub, should be printed as 
is a check book, and, whenever desirable, as in the case 
of acute infectious diseases, will, with small sheets of copy- 
ing carbon, give four forms, the original for the parent, 
the stub for the hygiene department, the carbon copy for 
the board of health as their notification, and the carbon 
stub for the nurse's or doctor's record. The notice can be 
sent home in several different ways, depending upon cir- 
cumstances. One of these exclusion books should be kept 
in each school, and for its pupils only. 

To avoid conflict of jurisdiction, the city health oflRcer 
and the director of hygiene, or superintendent, should meet 
and agree upon a plan of co-operation for readmitting 
pupils after exclusion or illness absence. The following is 
the result of such a meeting at Meriden, Connecticut, in 
the year studied and about a month after the work of 
medical supervision had begun: 

"It was agreed that the city health oflicer should write 
permits for returning to school after exclusion for small- 
pox, scarlet fever, diptheria and membranous croup, and that 
the school physician only should write certificates for re- 
turning to school after measles, whooping cough, consump- 
tion, chickenpox, mumps, sore throat, lice, scabies (itch), 
and other skin diseases, and other minor ailments." 

And it was furthermore agreed that the school phy- 
sicians should give no readmission for diseases assigned to 
the health department and the latter agreed to sign no 
permits to return for diseases assigned to the school 
physicians. Practically, then, the school medical service 



324 SCHOOL HEALTH ADMINISTRATION 

readmitted pupils for everything except scarlet fever and 
diphtheria, since small-pox is seldom if ever found. 

Notice of cases of acute infectious diseases like diph- 
theria, scarlet fever, measles, German measles, perhaps, 
small-pox, if ever found, and chicken-pox should be imme- 
diately telephoned to the city health department, the ex- 
clusion notice being sent later, if necessary. 

The board of health will, of course, notify the schools 
each day of all children ill with infectious diseases, quar- 
antined or not, and also when these pupils may be read- 
mitted. Such ailments whether found in the schools or 
not should be recorded on the record card and in the 
reports. 

Conjunctivitis, impetigo, trachoma and the parasitic ail- 
ments will be handled by the nurse. For trachoma, she will 
find it best to give instruction rather than treatment. 

Rare cases of tuberculosis should be reported to the 
superintendent or director of hygiene for special considera- 
tion. When diphtheria develops it is well to culture the 
throats of all children in the class to discover possible 
carriers. 

THE SPIRIT OF THE INSPECTIONS 

Let us remember that we are still in a primary room of 
a school in our typical city at the work of the September 
class-room inspection. A great deal will depend upon the 
spirit in which such work is carried on. Physicians are fre- 
quently very unpedagogical in their treatment of the chil- 
dren; and some of the cases of such unpedagogical treat- 
ment, witnessed by the author in dispensaries and at school 
inspections and examinations, would appropriately bear the 
title of "Crimes Against Childhood." Individuals, male or 
female, found unadapted for this personal, humane work 
with children should be relieved of it as soon as they can be 
discovered. The atmosphere of school medical work should 
be that of health, happiness, and co-operation, not that of 
so many of our public dispensaries. 



MEDICAL INSPECTION PLAN 325 

REPORTING THE ROOM-INSPECTION 

When the class has been room-Inspected, to coin a word, 
the nurse will take all the cards of ailing pupils to the 
principal's office or the health room, where they can be 
reported after the morning's work with the physician. In 
her case book for each school she will write down the 
name, address, room and ailment of each defective and ail- 
ing child and the date. When she sends notices home with 
the children who are ailing but not excluded and gets no 
satisfactory results in treatment within three days or a 
week, the time for a second notice, or for home visiting has 
come', which may even end with the doctor's visit or that 
of an officer of the law. After the list of cases has been 
placed in her book, the cards can be returned to the room, 
where the teacher will give them a separate place in her 
file, or mark them with colored clips. At the end of the day, 
the nurse will record all the work of inspection and the 
findings in the column for that day's work, on the weekly 
report form. This daily and weekly report will be treated 
under "examinations." 
b. Occasional Room-Inspections 

Occasionally, other room-inspections {special room-in- 
spection is a good term) must be made by the nurse atter 
the routine one in September. Very rarely will the doctor 
be needed for such work. The ailments found, she can her- 
self record; or, where there are very many cases she may 
find the co-operation of the teacher very helpful 1 he 
method can be that of the general inspection described, or 
she can simply pass along the aisles and mspect the chil- 
dren The latter can have their hands on the desks, and 
the nurse, passing along from the rear, can easily note the 
condition of the hair and scalp, as well as other features. 
The nurses of Newark made an average of nearly 500 
occasional class-room inspections each during the school year 
studied, besides about 21,000 individual inspections and 
over a thousand home visits each. These room-inspections 
-are especially valuable in poor, or foreign districts m bring- 



326 SCHOOL HEALTH ADMINISTRATION 

ing up the health and cleanhness standards towards that of 
civilized America. They are also valuable, as suggested, 
in the case of an impending epidemic. 
c. Individual Inspections 

Individual inspections are to be made principally by the 
nurse, but also, if necessary, by the physician in the one build- 
ing he visits for two or more hours each day. Only urgent 
cases are to be referred either by nurse or teacher to the 
doctor. The principal classes of individual inspections are 
as follows : 
w. Pupils referred at the time of the nurse's visit, by the 

teachers. 
X. Pupils entering that school for the first time, any age. 
y. Pupils who have been out of school for any reason more 
than three days, especially excluded, or quarantined 
cases. 
z. Pupils brought to the attention of the nurse in the homes. 

Where principals are, or become, qualified, a large num- 
ber of the readmittance inspections may be left to them. 
The importance of the health training of principals and 
teachers and the books they can use in study, will be brought 
out later. A principal who hasn't such a knowledge of 
children (child-study) needs to "study up." He must, how- 
ever, beware of cocksureness after little study. 

The usual place for the individual inspections is at the 
health room or the principal's office. A bell is rung indicat- 
ing the nurse's arrival. A school janitress or a good prin- 
cipal's clerk may be of great assistance in getting the chil- 
dren ready. Each child will come with his health record 
card in a fold of clean paper, and on this paper may be 
written the teacher's reason for sending in the pupil. He 
may be suspected of some ailment, or the teacher has noticed 
that he is not getting the treatment previously recommended, 
or for many other reasons, except as punishment. The 
nurse inspects the child, and, unless he is excluded, sends 
him back to his room, with a note to the teacher about the 
case on the same folder-protector of the card. The teacher 



MEDICAL INSPECTION PLAN 327 

may clip small memoranda slips on cards of pupils who have 
not yet obtained treatment, or put these cards in a special 
part of her file, or she may use the various colored clip- 
markers for card indexes, each color of which may be 
given a standard meaning, as before mentioned. 

The symptom chart prepared by Dr. E. B . Hoag and 
printed in his "Health Index of Children," and separately, 
or some other set of indices to school ailments, such as are 
used in Cleveland, or printed by the writer in American 
Education, or those given by Dr. Wood in his "Health 
and Education," will be of great assistance to the teachers 
In locating the children needing referring to doctor or 
nurse.* Most of the present work of medical inspection 
is really ^^^c/^^r-Inspection, since most of the cases are first 
noticed by the teachers and then sent in to the doctors. 
With all this responsibility the teachers have not been given 
a square deal in the way of health instruction in the form 
of lectures, clinics, teachers' meetings, or books, by which 
to fit themselves for their serious responsibility; and their 
normal or college courses have never, in most probability, 
even touched upon such matters. "The child," to their pro- 
fessional training institutions, was quite largely a disem- 
bodied mentality, and psychology was the only study of his 
nature. 

2. Environmental Inspections 

After pupil inspections, according to our outline, come 
environmental inspections. Home visits, or home hygiene 
Inspection, by nurses is about their most important work, 
and the problem of school sanitation will soon come up in 
any thorough system of medical supervision. The home- 
hygiene inspections at the time of the nurse's home visits 
are becoming exceedingly valuable citizen-making institu- 
tions, and no words here can Indicate the spirit, the pos- 
sibilities or the methods of that humane and scientific work. 



*See also the bulletin of the U. S. Bureau of Education, No. 524, 
pp. 130-131. 



328 SCHOOL HEALTH ADMINISTRATION 

We arrange for the records of such visits in cipher on 
each individual record card. Each nurse should obtain 
Dr. Hoag's or Dr. Cornell's book, and, at least, a book 
probably now published by the first school nurse of America, 
Miss Lina L. Rogers, R. N., now superintendent of school 
nurses at Toronto, and formerly of New York City. Dr. 
Dresslar's book on School Hygiene is also a desirable volume 
on the whole field. (Miss Rogers is now Mrs. L. R. 
Struthers.) 

In certain small cities the experiment has been suc- 
cessfully tried of making the nurse the attendance officer 
also (thus saving another salary as related), so that she can 
go to a home and handle a case of truancy effectively, as 
any other school "case." The possibilities have not yet been 
half discovered in this whole field of home visiting. Even 
where there are attendance officers, the nurse becomes their 
most valuable assistant. 

School sanitation inspection is more naturally the work 
of the superintendent, director of hygiene, principal and 
business manager; but the nurse and the physician should 
know enough about the subject from such texts as Shaw's 
or Dresslar's books on "School Hygiene," or the other 
books mentioned,* to do effective work in calling to their 
attention as often as is necessary evil conditions of lighting, 
cleaning, heating, ventilating, the condition of toilets, the 
necessity for play, playgrounds, and play apparatus, sanitary 
drinking fountains, the proper kind of dusting, and all such 
matters. 

The Board of Health of Philadelphia has a special card 
form, for recording the facts of school sanitation, and Dr. 
Hoag has a portion of his book and a pamphlet devoted to 
a "Sanitary Survey of Schools," which is of great assist- 



*Dr. Jesse D. Burks and his wife have published a new book en- 
titled "Health and the School," and the writer has one under way 
entitled "School Health," as well as a large volume by a large group of 
specialists entitled "Educational Hygiene" from kindergarten to uni- 
versity. The Burks' book is unique, being in dialogue form. Terman & 
Hoag will soon have out a valuable volume on "Health Work in the 
School." We need still more volumes — on School Clinics, on School 
Nursing, on Medical Supervision, etc. 



MEDICAL INSPECTION PLAN 329 

ance to the amateur, and which can be had of Whitaker 
and Ray-Wiggin Co., San Francisco, or Paul Hoeber Co., 
69 East 59th St., New York City.* Quite frequently the 
nurse or the school physician will observe unhealthful condi- 
tions not noticed by teachers or principals, and, then, may 
be even more successful than they in remedying these condi- 
tions. It depends upon who has the ability to translate 
private opinion into public opinion, and private scientific 
knowledge into public action. 

C. Examinations. 

There is no need of calling these physical examinations, 
except where the word examination is (badly) used for in- 
spection. We have suggested that a thorough, routine room- 
inspection of children for all ailments of a serious character, 
recorded on the health record cards, is very much like an 
examination. It is, however, not so individual, so intensive, 
and so technically diagnostic. Inspections will frequently 
overlook decayed teeth entirely, and will never include 
routine vision or hearing tests, nor will they ever require, 
perhaps, the stripping of each child to the waist, as a mat- 
ter of routine and without suspicion of some heart or lung 
ailment. An examination should be a patient, scientific, 
investigation of a child's health status, regardless of whether 
he is suspected of an ailment. Such examinations should not 
be painfully long, and impractical, however, in their min- 
utiae. Quick, accurate and thorough observation and judg- 
ment can be developed in this field as in any other. Much 
will depend upon the physician and the nurse and what 
they have in their minds as questions and problems regard- 
ing each child's health condition. 

The examinations should be made in the health, or 
medical, room. This should be about half the size of an 
elementary school room (25 by 16), and be well lighted. 
It should have both hot and cold running water, a toilet 
adjacent, facilities for a combination tub and shower bath, 



*See also the New Jersey form of 114 points in the U. S. Bulletin, 
No. 524, pp. 127-9. 



330 SCHOOL HEALTH ADMINISTRATION 

a couch, several chairs, an ante-room for those awaiting ex- 
amination, filing cabinets for case cards (for systems need- 
ing them), a table or desk or two with drawers, a medicine 
cabinet, a white enameled iron and glass stand, white enamel 
wash basins, and the various test cards, medicines, and the 
like, needed by nurse and physician. Types of equipment 
and supplies are given in a former chapter. Many schools 
add to these a platform scale, usually a "Jones," with height 
standard attached. Its necessity as a matter of general 
routine for all school children is yet to be demonstrated, 
however. 

THE METHOD OF THE EXAMINATIONS 

As suggested, it will probably be best for the nurse to be 
present each day during the two hours or more of the 
examination, so she can confer with the physician over cases 
and help in handling the children, making the vision and 
hearing tests, taking the records, etc., as can best be ar- 
ranged. Scientific management in business does some of its 
best work with seemingly minor details of daily practice. 
There is great opportunity for the practice of its principles 
in medical supervision and especially in the examinations. 
This plan, however, must limit itself to bare essentials, in 
order not to exceed all space limits. 

We have urged that the vision and hearing examinations, 
once a year or less often, as is found better, be given by the 
nurse and not by other persons; and that she do this, as 
much as possible, at the time the physician of her district 
makes his two-hour daily visit to some one school. One 
nurse will work with the physician at all times while the 
extra nurses will devote themselves to inspections and home 
visiting. 

Here, at the ringing of the bell which indicates the 
physician's arrival, or before, children suspected of having 
serious ailments or who for some reason require immediate 
attention are sent by the teachers or nurse to the health 
room. At the same time, pupils of the lowest grades, a 
room at a time, are sent, by threes, to the health or medical 



MEDICAL INSPECTION PLAN 331 

(inspection) room. The nurse quickly inspects the serious 
cases, referring such as are puzzling to the doctor for 
further inspection, and then disposes of the first group. If 
desired, they may be examined at this time. 

She then prepares, as may be necessary, a child (of the 
three mentioned) for the doctor's examination, calling his 
attention to any ailments or history of the child familiar 
to her and necessary for him to utilize, and begins, herself, 
to test the vision and hearing of another child. By the time 
the doctor is through with his medical examination she will 
perhaps be through with these two tests, and all can be 
recorded on the health record card of the pupil, exclusions 
can be made, or notices to parents regarding serious physical 
defects or other ailments signed. Each case (name of child) 
will be placed in her case book, or on a case-card on file in 
the health room or principal's office. Such cards for de- 
fective pupils are found necessary in many cities. The one 
used by Newark is sent to the "department of medical in- 
spection," when the case is concluded. Cards not sent in by 
the end of the school term are used for follow-up work in 
the summer. Whenever a case is concluded, the teacher 
should be notified. The word "case" is frequently used to 
mean both a single child and all his ailments at any one 
time, and again each one of the ailments found, so that a 
child might be six or more cases at once. If the term is 
used (and it probably should not), it should refer only 
to one child with all of his ailments, whether one or many, 
at any one time. Usually every new ailment he gets will 
make another case. Then instead of recording the number 
of "cases," the number of different ailments should be given, 
and for a large group of children there will always be more 
ailments than pupils, probably, on the average, two or more 
to one. 

The time of the examination should preferably be from 
nine to eleven each day, and each day in a different school 
during a week or longer, depending upon the number of 
schools it takes to supply about three thousand children, de- 
pending somewhat upon the locality, of course. Perhaps 



332 SCHOOL HEALTH ADMINISTRATION 

two thousand for the doctor and the same or fewer for the 
nurse may be found desirable in a poor, foreign district. 
For small schools the doctor's visits should be distributed 
over the year. A school with 200 pupils will mean about 
10 visits, or one every three or four weeks. Compromises 
may be made here. 

If the nurse and doctor go to the same school, how can 
we have inspection at other schools each day, someone may 
ask? This is one of the reasons for the extra nurse in the 
typical city. She will do this work. Otherwise, the prin- 
cipals and teachers must use their discretion as they have 
done for so long, until the nurse can come in the late morn- 
ing or in the afternoon. Some of these daily inspection 
visits she can avoid by telephoning to a school and finding 
whether the teachers have looked and found any urgent 
cases. On schedule, she will probably get to one or two 
of these other schools each afternoon anyway. 

THE VISION EXAMINATION 

Whether vision and hearing tests should be made each 
year is a question. Abroad, all examinations are less fre- 
quent than here. A modification of the plan of Meriden, 
Connecticut, commends itself to our judgment, as a tentative 
hypothesis : that of tests for new children whenever they 
enter the school above the kindergarten, and every other 
year thereafter, i. e., the first, third, fifth, seventh, ninth, 
etc. The three-year interval there practiced would seem 
too long. 

For the method of the examinations in detail, nurses and 
doctors should refer to some such book as that of Dr. 
W. S. Cornell (Health and Medical Inspection of School 
Children). Whipple's methods given in Monroe's Cyclo- 
pedia of Education under the topics, "Ear" and "Eye," 
are also commended. The methods given in Gulick and 
Ayres' Medical Inspection of Schools, are well chosen. 
With all their defects as complete tests, the Snelling's or 
other test types for capacity to read at twenty feet, and for 
astigmatism, must be, until we get better trained nurses and 



MEDICAL INSPECTION PLAN 333 

physicians for this work, our chief reliance. The ap- 
paratus recommended by Whipple consists of: a test card 
for acuity, a test card for astigmatism (preferably Ver- 
hoeff's chart), a simple trial frame into which may be fitted 
during the examination either one or two minus .75 ^ and 
one or two plus .75 d spherical lenses (48-inch focus, 
English system), and one blank disk. Probably better than 
the trial frame into which may be set the two types of lenses, 
are cheap spectacle frames fitted up, respectively, with the 
plus and minus glasses. These are for those, however, who 
have the interest to go forward and do accurate work, and 
will probably be used only where there is a director of 
hygiene. Another instrument, the retinoscope, the shape of 
a small paddle with a mirror and letters on its face, tests for 
three types of defects, and is good for quick general diag- 
nosis for those who learn how to use it. 

But just as important as the test, is the examination of 
the general condition of the pupil's eyes, whether inflamed, 
crossed, seemingly strained, whether the child has frequent 
headaches, how he holds his head, as well as the note by 
the teacher which she places on the paper in which each 
child carries his examination card. 

Place the test card in a good light at a distance of 
twenty feet on the level with the pupil's eyes, and stand the 
child in such a way as to avoid any reflected glaring light. 
Children wearing glasses are to be tested with the glasses 
on, and if normal with them, so recorded. Pupils who, at 
twenty-foot distance, cannot read the line of letters marked 
twenty feet should not be counted defective (unless there 
are other signs of eye strain and ocular defect). Only those 
whose vision in either eye is 20/40 or less (each eye always 
tested separately and then, perhaps, both together) should 
be counted defective, with the exception mentioned. Test- 
ing with both eyes open has the advantage of showing what 
the best vision of the child is in ordinary circumstances, but 
also the disadvantage that it measures principally the vision 
of the stronger or better eye. As a check, it may be omitted 
as a routine matter, perhaps, and each child studied as a 



334 SCHOOL HEALTH ADMINISTRATION 

separate problem. If both eyes always varied together, 
mechanical methods, almost, might be employed. Unfor- 
tunately, the children strain and accommodate their eyes 
during the test. The best statement of the whole problem 
here is perhaps that given by the head of the vision de- 
partment of the school clinic at Dunfermline, Scotland, in 
the 1911-12 report, distributed so freely by the Carnegie 
Trust of that place. The following pupils, as a general 
rule, should be referred as possibly defective and in need 
of the attention of an oculist: 

a. All pupils showing signs of eyestrain, inflammation, 
headaches, etc. 

b. All pupils with vision 20/40 or less in either or both 
eyes. 

English and Scotch reports usually give the following 
in the report : 

1. Number at different ages with "normal," 20/20, vision. 

2. Number at different ages with "good," 20/30, vision. 

3. Number at different ages with "fair," 20/40, vision. 

4. Number at different ages with "bad," 20/60, vision. 

The data by sexes are, also, frequently given, although 
probably unnecessarily. Most children are reported to 
parents who are 20/40 or less. The following for all the 
pupils of Dunfermline shows either an improvement in 
visual conditions, or a change in methods by the examiners, 
or both: 

1910. 1911-12, 

Boys 20/40 or worse 6.4% 5.1% 

Girls 20/40 or worse 12.5% 7.4% 

The duty of the nurse is to get those books which will 
help her best, and also to obtain help from oculists, and to 
visit other school systems with good medical supervision 
systems. No plan can take the place of a live, inquiring, 
sympathetic intelligence. 

HEARING TESTS 

As the eyes were tested singly so Is the hearing of each 
ear. The whisper test and the stop-watch tests will be of 
value. As with vision, the individuality of children is such 



MEDICAL INSPECTION PLAN 335 

that the best standard yet is common sense, conservative 
common sense in this matter. The tragus or projecting por- 
tion of the ear may be pressed easily into the cavity, and 
the stop-watch started and stopped and the child, not seeing 
it, asked if he hears it. What is asked may be whispered 
quite softly. Numbers and short sentences may be used. 
The standard may be an ordinary soft whisper at the dis- 
tance of the vision tests, twenty feet, this probably being 
the greatest length of the room used. Only a very few 
children in each school will probably be found with this ail- 
ment, usually preceded by discharging ears. 

All three or four of the children awaiting examination 
may be tested at once by standing them with their backs 
to the nurse and whispering commands, or asking that all 
who hear the stop-watch at various distances hold up 
their hands, etc. The difficulty of one pupil imitating an- 
other may easily be overcome. The growing experience of 
the nurse gives a norm or standard probably of more value 
than that of an audiometer, though the development of 
such objective standards should be encouraged in all this 
work. The observations of the teacher and parent as to 
the children's condition should always be sought as a help 
in examination. 

Both examinations have taken less time, of course, than 
to read the lines here given in explanation of the work, 
probably two to five minutes for each pupil, making records 
and all. 

THE doctor's medical EXAMINATION 

The child having been tested for hearing and vision and 
the results, if below 20/40, placed on the record card for 
each eye, or, the numerical record for any degree of de- 
fect as may seem better, he passes on to the physician who 
gives him a thorough medical examination, loosening the 
clothing, removing the coat, or even stripping him as ap- 
pears necessary for the best examination. The parents of 
twenty or more children have been notified of the approach- 
ing examination on this day and it is desirable that as many 



336 SCHOOL HEALTH ADMINISTRATION 

come as possible. If a parent is present, all the children of 
the family in that school should be examined on that 
morning. 

The doctor looks, not for a few ailments, but for all on 
the code and report list. Some of the more easily missed 
ailments, he will give particular attention to, and especially 
those placed in the upper part of the list of physical de- 
fects. If a doctor finds few cases of enlarged glands one 
year and then later learns of their possible harm to the child 
in his school work, it has been found in our study that he 
will then begin to find many cases where he had not seen 
them before. What a man is so sees he, is the law of medical 
perception. 

The doctor, especially, must be careful to calm the fears 
of the children and put them at their ease. It is all too 
customary a habit for children to remain out of school on 
the days when they know that the doctor is coming. Some 
teachers use the doctors as disciplinary bogeys, a great 
mistake. English school physicians may go about with silk 
hats and frock coats, but many of them carry a bag of candy 
("sweets") of which to give to each child examined. One 
of them who has written a book on the work says it has 
many advantages. The attitude is the important thing. 

As the doctor makes his examination he records any seri- 
ous findings needing attention by parents and family phy- 
sicians on the health record card. The system of signs makes 
it possible to do this very rapidly and with little waste of 
time. Here has been one of the greatest leaks, and almost 
as great as that of having the doctor travel about from 
school to school every morning on inspection tours, in many 
of the present systems of so-called "medical inspection." 

Whenever a referable, non-infectious ailment is found 
in the examination or the inspections, the following note to 
parents may be filled out from the cards and inclosed in an 
envelope by the nurse, after the examination is over some- 
where near eleven o'clock: 



MEDICAL INSPECTION PLAN 337 

Medical Supervision of Schools, 
Montclair, N. J. 

NOTICE TO PARENTS OR GUARDIANS. 

This notice does NOT exclude the pupil from school. 

Date , 191- . 

The parent or guardian of 

is hereby informed that a physical examination by the school physician 

seems to show that this child is suffering from 

You are advised to take 

this child to your family physician or a specialist, 

for advice and treatment as soon as possible, in order that the pupil 
may be better fitted to do successfully and without injury his school work. 

School Physician. 

This notice may be placed on a card of a certain color, 
say yellow, and about 55^ by 3/4 inches in size. Some 
send all such messages by post, but this is in most cases a 
needless waste. 

On the back of the card may be printed a permit by the 
parent for the nurse to take the child to a clinic or physician 
for medical or surgical treatment, and an alternative state- 
ment that the parent has had a physician and the result of 
the visit, somewhat as follows : 

PLEASE SEE THAT THIS CARD IS RETURNED TO THE TEACHER. 

This pupil was seen by Dr on 

, 19 .... , with the following result 



Signature of parent or guardian, 
I desire the school nurse to escort my child to. 



for medical or surgical treatment of the. 
Signature of parent or guardian. 



338 SCHOOL HEALTH ADMINISTRATION 

If the parent does not respond within three days, and an 
inspection at that time by the nurse shows no evidence of 
satisfactory treatment, another notice should be sent. 

If this notice is not heeded, and it should be printed and 
worded in such a manner as to command attention and get 
results, the nurse may visit the home to help the parent see 
the need of the treatment or to explain and arrange with 
her the free treatment at some dispensary, the school clinic, 
or other similar place. If the nurse is unable to get the 
treatment, and cannot do it herself, the physician, principal 
or teacher may attempt the matter. 

So many parents are so poor and so ignorant, and the 
provisions for treatment are so inadequate or unsatisfactory, 
that men and women in the school medical service are soon 
driven to see the absolute necessity of an adequate school 
clinic, with an oculist to make eye examinations and pre- 
scribe and, at times, furnish free glasses, dentists for dental 
service, and surgeons for operative work. The surgeons 
or the nurses attached, or a school physician, can make such 
treatments as are necessary — those for ringworm of the 
scalp with X-rays possibly, for favus, for trachoma, ade- 
noids, tonsils, etc., and, with the help of the physical educa- 
tion division, such medical gymnastics as are needed for 
orthopedic, mouth breathing, and other cases. The need 
for an open-air school, and outdoor cooler ("uncooked") 
and moister air in the classrooms, will also soon be made 
manifest in even the best of cities. 

As the examinations extend through the entire year, 
and the graduating class of February may not be reached 
by that time, it will be well to give this class an examina- 
tion early in the term. Other children who may also be 
examined out of turn are : the children of a family when a 
parent has come to the examination, as suggested, children 
going into athletic contests (very important In some cities), 
children who are especially referred to the physician by the 
nurse, or to the nurse by the teacher, and children who have 
entered school, or that school, for the first time after the 
pupils of their rooms have been examined. 



MEDICAL INSPECTION PLAN 339 

Not only parental visiting at the examinations is desira- 
ble but also school consultations with nurse or physician, 
when the parent has neglected treatment for the child, for 
instance. A notice such as the following may be sent, at the 
end of the three-day period mentioned: 

DEPARTMENT OF MEDICAL SUPERVISION OF SCHOOLS. 

Date , 19 

To the parent or guardian of 

Public School 

You were notified a few days ago that this child was found on 
examination by the school physician nurse to be in need of immediate 
treatment for 

Please call at the school at o'clock 

to confer with the school physician nurse. 

Principal. 

Cross out either "physician" or "nurse" where they are 
printed for alternative use. This card may be white in 
color and 3/4 by 5/^ inches in size. Other devices to 
obtain treatment will be invented by the thoughtful and 
interested nurse, physician, or principal. Some cities use 
attendance officers to force children in whom the doctor or 
nurse will not admit till treated or cured. Notice is also 
sometimes sent that parents are keeping children out illegal- 
ly, even though excluded or referred for treatment. 

When the time has come, three days after notification, 
and the pupil is in school, the teacher sends the pupil in 
for the nurse's or physician's inspection to see if the cure 
has been obtained. No record of cure or treatment is ever 
to be made without such inspection. The teacher's opinion 
is not enough. Dr. Foster, of Oakland, Cal., has his nurses 
record cures at the first routine inspection only, and these 
for ailments found the year previous. Cures take time. 

A further attempt at accuracy, co-operation, and a check 
on the work of doctor and nurse, is the principal's monthly 
report based upon his own and the teachers records. This 
will be described later. 



340 SCHOOL HEALTH ADMINISTRATION 

Great care must be taken not to give the impression 
that the nurse and physician are interested in providing 
patients for the doctors, dentists and oculists of the town. 
They are not; and one of the great reasons for the school 
clinic is to break down this argument not only of the medi- 
cal fakirs so busy everywhere just now, but also the plain 
common-sense parents of the children. Dr. Chapin of the 
Providence Board of Health in his 1910 report and again 
in the one for 191 1 has met a number of the criticisms 
of such free treatment, especially that it would injure the 
pocket-books of private medical people. 

It is probable that if all the children of the nation were 
given free medical attention and treatment until the age 
of sixteen, as is almost the case now in Boston since the 
completion of the Forsythe Dental Clinic, and all children 
educated in right health habits and the necessity of getting 
the help of dentist and doctor where their services are 
necessary, the medical profession as a whole would lose 
but little, and the nation as a whole would be immeasur- 
ably improved. Free schools, free text-books, free libraries, 
free baths, free music in the parks, free postal service, free 
medical service for old and decrepit already : and why 
not free treatment where necessary, and rather generously, 
for the young and plastic, before they lose all their per- 
manent teeth, perhaps, or the use of an eye, or the hearing 
of an ear? The bugaboo of "Socialism" hurled in 1828 
at the speaker for free schools on the court house steps 
of Philadelphia leading to his arrest, and used so freely 
ever since, provokes no fright any more in the hearts of 
those who would minister to the health and happiness of 
this people. Selfishness will be swept into its deserved 
oblivion, before this advancing democracy and scientific 
brotherly love. Compulsory school attendance involves free 
and compulsory health provisions. These, when established, 
will point to certain necessary social reforms, of a far-reach- 
ing character, probably socialistic in tendency. 



MEDICAL INSPECTION PLAN 341 

VACCINATION FOR SMALL POX 

No one has yet proved that small pox vaccination is 
not necessary or desirable for all school children. Many 
cities are experimentally doing without such requirements 
in the schools, and the ailment does not seem to get a 
start in such towns. However, much experience points to 
its value even if the disease seems to be losing its virulence, 
and probably the best plan to enforce is that no child shall 
be admitted to the schools a day without such vaccination. 
Free vaccination should be provided by the schools or board 
of health for such purpose, and the work done by the 
nurse or physician. Re-inspection to observe the effect of 
the vaccine should be made as in the case of other treat- 
ments. Here the nurse will often find it necessary to make 
dressings for the vaccination sores. In Philadelphia, ac- 
cording to Burks, laxity in the prevention of small pox 
cost the city in 189 1-2 through an epidemic over $21,000,- 
000, and another outbreak in 19 12 in Penns3'lvania towns 
was only checked by wholesale vaccination. 

EDUCATION OF THE PARENTS " 

For many or most of the fifty-four ailments and classes 
of ailments parents can be given judicious health instruc- 
tion, as to treatment, reference to doctors and prevention. 
The book by Dr. Ditman on "Home Hygiene and the 
Prevention of Disease," by Dufl'ield and Co., or one just as 
good or better, if any, should probably be in every intelli- 
gent household. Much of our recently discovered health 
knowledge has been the almost secret possession of the few. 
While there is some little danger in home treatment there 
is no danger in home prevention, and a book along the 
line of health education in the simple language of the people 
is necessary to democratize our health knowledge. This 
latter desire is also back of the simpler nomenclature used 
in the present system of medical supervision. An examina- 
tion of the list of school ailments given in the 19 10 or 
19 II reports of the Boston Board of Health, and other 
such cities, will show what to avoid in this field. 



342 SCHOOL HEALTH ADMINISTRATION 

Do you know, lay reader, what urticaria, verucca, fur- 
unculus, acne, tinea, scabies, pediculosis, and such names 
mean? They are respectively: hives, warts, boils, black* 
heads, ringworm, itch, and head lice. Such terminology 
for diseases thrown at parents is defended by saying that 
"it scares them into getting treatments." We say simply 
that these are the undemocratic methods of persons who 
do not know how, in the best way, to educate the people 
into independence and self-respect. Let schools using and 
adapting this system get close to the people and their needs 
and their problems, not high in the air above them, or 
behind some awesome word and mysterious profundity. 

We shall not attempt here to describe all the good 
methods now being used by schools to reach the parents, 
or to devise an ideal and general plan. For brevity, only 
a list of some of the more interesting attempts, and where 
they can be found, will be listed: 

1. The various colored prescription slips for a growing 
variety of ailments, to be found in Newark, Providence, 
New York City, and shown in "Medical Inspection of 
Schools," by Gulick and Ayres, new edition. 

2. The dental charts showing the location of defective 
teeth, given out with defective teeth notices in many cities, 
one form given in the book mentioned; also the various 
pamphlets such as are given out by the Bath Trustees, City 
of Boston (on teeth), the Children's Aid Society of New 
York, the various pamphlets of Dr. E. B. Hoag of Berke- 
ley, California; the prescriptions for getting compounded 
very cheaply serviceable tooth powder, by the Board of 
Health of New York City; the Newton, Mass., Board of 
Health pamphlet on "Information for the Family in Re- 
gard to Communicable Diseases," etc., etc. 

3. The health lectures given by school nurses, doctors 
and principals, and outside specialists, often with the aid 
of the stereopticon. Newark records 346 such lectures in 
the school year of 1910-11. 

4. The tuberculosis and other exhibits, stationary and 
portable. 



MEDICAL INSPECTION PLAN 343 

5. The health budget exhibits showing the need for 
appropriations for medical supervision and other phases of 
educational hygiene. 

6. Pamphlets on infant and child hygiene for parents. 

7. Pamphlets on sex hygiene. 

8. The remarkable variety of ways described in Elsa 
Denison's "Helping School Children," showing that "where- 
ever there is a will there is a way." 

9. The constant and varied use of the newspapers for 
describing school health needs and what parents can do 
to help. 

10. The annual health day or health week in the schools, 
as in Boston. 

11. Above all, the splendid services of the wide-awake 
and resourceful school nurse going to the homes and help- 
ing the family in their struggles with the real health 
problems of life. 

THE WEEKLY REPORT OF DOCTOR AND NURSE 

Our nurse does all the general reporting. Any ade- 
quate report will always show in juxtaposition the ailments 
found by both doctor and nurse and what has been done 
with them, quite in contrast to most of the reports now 
given out to the public by school superintendents or direct- 
ing physicians. 

Some of the standards for such a report are: 

a. It must be simple and take up as little time as pos- 
sible and yet give the facts necessary for the proper educa- 
tion of the public, and the accurate recording and study 
of health data necessary for school health control. 

b. It must show the ailments found in detail, if possible, 
and give the curative results obtained by the department. 

c. It must record the work done by the different mem- 
bers of the corps and the time they spend in the school 
service. 

d. It must use some standard classification and nomen- 
clature of school ailments, not only for the uniformity 
necessary, and the ease of memorizing a relatively un- 



344 SCHOOL HEALTH ADMINISTRATION 

changing outline, but also for dividing the work naturally 
and emphasizing by position those ailments which play a 
large part in the success or failure of the pupil in school 
and life. 

e. It must ehminate as much as possible the writing-in 
of the names of ailments. A great many reports print only 
names of ailments which occur with extreme rarity and 
the doctor and nurse must spend much time in writing-in 
many ailments or else neglect to report them. The result 
is commonly neglect, with large numbers of important ail- 
ments unreported. 

/. The form should be such as will make possible a 
balancing of figures if possible, somewhat as the monthly 
reports of teachers and principals are made to balance. 
This is a difficult matter. Nurses must learn by study how 
to make out the report, just as they would learn to use 
any other instrument, say, a typewriter. 

g. It must show the work by days, and by the week, 
and must record both old and new ailments, making it pos- 
sible for the superintendent to know at any time of the 
year how many cases of uncured school ailments there are 
in the schools and, perhaps, in any school district. "Old" 
ailments are those found at any time during the year before 
the week reported. "New" ailments are those found dur- 
ing the week reported. Daily reporting may be used in 
large systems, but we are dealing with the more typical 
cities and rural districts. 

h. It must show the number of new ailments found not 
only by the doctor but also by the nurse, their sum, the 
number to be subtracted because "negative," left the city, 
refused treatment, etc., and what happened to those left. 

i. It must record exclusions, treatment by nurse or out- 
side agencies, cures found by re-inspection, number read- 
mitted, and the number "improved but not cured" in a case 
where cure is a matter of months or years. 

;. The report will be not only an ailment report, but 
also a report of the number of examinations, home visits, 



MEDICAL INSPECTION PLAN 345 

inspections, pupils taken to the dispensary, etc. If possible, 
the nurse should report weekly the total number of various 
ailments to date that have been found, cured, and not cured, 
with perhaps the number treated and not treated. 

This will greatly reduce the work at the central office. 

k. The report should also give explicit directions as to 
the way to use it, and should interpret all terms to be used 
that are shifting in their meaning. All such directions 
should be printed on the report form itself, if possible. 

/. It should also provide for a report on school sanita- 
tion, notes and recommendations, record of special cases, 
and any other data that cannot be given in figures and 
must be written out. The attempt to put every phase of 
reports dealing with such intimate and personal matters 
as these into the squares of report forms by a system of 
checks or figures easily m'akes for mere routine mechanics. 
We must have both the form and the spirit, the technically 
definite and the flexible. 

Instead of printing the large 10x15 report here, we give 
the headings and other matter necessary to reproduce it. 

THE FORM OF THE WEEKLY AND ANNUAL REPORT 

We give above photographic reproductions of the head- 
ings of two sides of our tentative and suggestive weekly 
report. It can be modified as desired. The form is about 
ten by fifteen inches in size, and should be printed with black 
and red and with perhaps blue lines to make easily dis- 
tinguishable the various divisions. The upper half of the 
face containing the name of the city is the general summary 
of work done : schools visited, time spent in the schools, etc. 
The lower half of the face page is divided vertically by a 
line continuing the line to the right of Wednesday or Thurs- 
day above. To the left of this line below should be printed 
specific numbered directions for making out the report such 
as appear below, while to the right below is the heading 
"G?bneral Notes to Supervisor of Hygiene," under which 
is to be written in any notes to supervisor, superintendent, or 
board of education on such matters as : special cases, recom- 




346 



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348 SCHOOL HEALTH ADMINISTRATION 

mendations, home hygiene, school sanitation, co-operation of 
outside agencies, special health needs of the schools, supplies 
desired, work of open air school, why certain cases are not 
treated, the chief difficulties, control of epidemics, personal 
stories of cases for the newspapers, etc., etc. 

On the other side of the report sheet is the "Detailed 
Report of Ailments," the term ailments covering all affec- 
tions of children of a pathological character. Vertically on 
the left are placed the 54 classes of ailments In four divisions 
with three or four lines left at the end of each division for 
writing in any special cases that cannot be placed in any of 
the above divisions. We give only the heading and the side, 
but the report may easily be duplicated in full by extending 
the lines. It looks formidable but nothing less, it seems, 
will keep before physicians and nurses the ailments they 
should look out for; will make easy the detailed recording 
of ailments; and will keep a definite unchanging order easily 
memorized by use. This report will be entirely made out 
by the nurse in red ink, on Saturday afternoons with the pro- 
viso that It is to be in the hands of the supervisor or superin- 
tendent by Monday at nine o'clock A.M. The chief weakness 
of the report is that it does not entirely separate the data 
by schools, although this will be done to a large extent where 
only five schools are visited each week by the medical ex- 
aminer, Monday being very largely the cases found at one 
school. Records will, of course, be kept at each school for 
the year and these may be called In at the end of the year 
for the annual report. We are not trying here to provide 
a system for a large city like Philadelphia or even Newark 
or Boston, but for average cities, around twenty to a hun- 
dred thousand population. Dr. Burks has met the Phila- 
delphia type of situation in his new book on Health and the 
School. The following directions may be printed on the 
report : 

DIRECTIONS FOR MAKING THE WEEKLY REPORT 

I. This report is to be made out by the nurse at the end of each 
day's service and summarized on Saturday afternoons for each week 
just passed. 



MEDICAL INSPECTION PLAN 349 

2. It must be delivered at the office of the Supervisor of H\'giene 
or of the Superintendent of Schools by nine o'clock each Monday 
morning. 

3. Every effort must be made to make it strictly accurate. No 
very minor unreferable ailments should be recorded — only those which 
need serious attention by the schools or the homes or both ; and every 
reasonable effort should be made to have these ailments treated and 
cured. 

4. The schools will be numbered in arable numerals and should be 
so designated on the reports. (For small systems with few schools 
the names of the schools with their code numbers may be printed in 
the blank space or spaces at the top of the report under the words 
"General Summary.") 

5. Time spent in the schools at medical work will be recorded in 
hours and decimal parts of hours — two hours and a half equalling 2.5 
hours. 

6. Room inspections should be recorded according to the number 
of rooms and not the number of pupils. 

7. No pupils should be reported for more than one complete (phy- 
sical) examination each year. All other physical studies of the pupils 
will be recorded as inspections. 

8. New ailments are those found during the week reported; old, 
those previously reported. 

9. Under number of ailments treated "other" or "O" refers to 
any agencies outside the schools that have treated the pupils. 

10. Under "Remarks" any explanatory information may be written 
regarding the records to the left. Under "General Notes to Super- 
visor of Hygiene" any general reports, requisitions, special cases, recom- 
mendations, or the like, may be written in. 

11. On the back of the report is the "Detailed Report of Ailments." 
Space is left for writing in the names of ailments not in the classifica- 
tion. 

12. "Negative, Subtract" refers to ailm.ents previously reported 
that have since been inspected by a family physician and declared "no 
case" or not serious enough to warrant treatment or operation. Pupils 
in any way leaving permanently the school system should also have 
their uncured ailments subtracted from the previous reports. 

13. The "Grand Total of Number of Ailments to Date" is a brief 
summary of the year's work to date. In the "Not Cured" column 
should stand the exact number of ailments in the schools reported on 
that are not yet cured, so that the school officials may see at a glance 
just how many adenoid, impetigo, or diphtheria "cases" or ailments 
exist at the time among the school children. 

14. All ailments of school children, especially the more serious ones, 
whether found in the schools or not should be here recorded. This 
applies particularly to "Infectious Diseases." 

1%. If there is an assistant, i. e., one besides the one who works 
daily with the physician, for this group of children, she should report 
her work to the first nurse who will incorporate the data in this report. 



350 SCHOOL HEALTH ADMINISTRATION 

CLASSIFICATION AND FREQUENCY OF AILMENTS 

We give below our classification of the ailments found 
in the twenty-five cities investigated with the probable num- 
ber of these ailments which will be found in any one school 
year among a thousand elementary pupils, more in the lower 
grades than In the higher — although we have shown previ- 
ously that, according to the Newark report of high school 
ailments, they are much the same and almost as frequent 
as for elementary pupils. The amount and kind of varia- 
tion we are not yet ready to estimate. 

Probably the most variable ailments in the list are the 
infectious ; the frequencies given will for most cities merely 
indicate the number of actual ailments or carriers that will 
be found In the schools, and will not be large enough to 
give the medians for all the actual "cases" in the year. 
Yet all such cases, whether found In the school or not should 
be recorded. They cause absence and lowered vitality, and 
various physical defects such as weakened vision, defective 
hearing, etc., that are of much concern to the schools. A 
first-class system will also, through summer nurses and fall 
Inspections, get records of all serious summer ailments of 
the children. 

If each physician with one or two assisting nurses has 
three thousand pupils we can multiply these frequencies by 
three to see what the totals will be for the year. Very 
great variations should be investigated, but may be, of 
course, entirely normal for those pupils. 

There are about 1,419 ailments for the thousand chil- 
dren if our estimates are anywhere near the true medians 
for average cities. Later investigations may make possible 
a statement of reasonable variations from these average fig- 
ures, and may also show how they vary for different kinds 
of cities and for different kinds of districts within cities. 
We have not been able to get very satisfactory data on these 
problems. Poor and foreign families generally furnish most 
ailments, especially, perhaps, Russian Jews, South Italians, 
and Irish, although the native "poor white trash" seem to 
be in about the same group. 



MEDICAL INSPECTION PLAN 351 
I. NON-COMMUNICABLE AILMENTS. 

A PhvciVal Tiffprte Probable No. Ailments 

A. rnysicai i^etects. per 1,000 Ei. Pupils 

1. Adenoids, nasal obstruction, etc 50 

2. Anemia lO 

3. Deafness, defective hearing 5 

4. Dental, teeth 660 

5. Enlarged tonsils 60 

6. Eyesight, vision 70 

7. Eyes crossed, strabismus, squint 7 

8. Glands enlarged, adenitis lO 

9. Heart defects 9 

10. Lungs very vi^eak, not tuberculosis 5 

11. Malnutrition, debility, indigestion, general condition. 20 

12. Mentality lO 

13. Nervousness, chorea, habit spasm, nervous exhaustion 2 

14. Palate defects 7 

15. Skeleton, orthopedic defects (flat-foot, club-foot, etc.) 2 

16. Spine: curvature, posture, round shoulders, etc 8 

17. Speech: stuttering, stammering, lisping, etc 9 

B. Common Ailments. 

18. Abscess, boils, etc 5 

19. Acute sore throat, cough, etc 3 

20. Bronchitis I 

21. Cleanliness needed 20 

22. Catarrh, rhinitis lO 

23. Colds, bad. Coryza 30 

24. Ear discharge, otitis media 15 

25. Ears: ear wax (impacted cerumen), foreign bodies, 

etc.. Minor 5 

26. Eczema 7 

27. Eyes: "sore," blepharitis, styes, iritis, etc.. Minor... 20 

28. Headache (a symptom), migraine, neuralgia 15 

29. Laryngitis 5 



352 SCHOOL HEALTH ADMINISTRATION 

30. Nose-bleed, epistaxis 2 

31. Pharjmgitis, chronic sore throat 3 

32. Rheumatism I 

33. Sex ailments and habits 10 

34. Skin ailments, minor; herpes, seborrhea, acne (black- 

heads), etc 15 

35. Stomatitis, mouth ulcers, "canker sores" I 

36. Wounds, sores, sprains, poison-ivy, chilblains, "first- 

aid," etc 150 

37. Urinary ailments, incontinence of urine, eneuresis. . . 2 

II. COMMUNICABLE AILMENTS. 

A. Parasitic and Minor Infectious Ailments. 

38. Conjunctivitis, "pink eye," etc 30 

39. Favus, yellow^ scalp sores i 

40. Impetigo "contagioso," infectious sores 20 

41. Influenza, grippe, infectious colds of a serious char- 

acter I 

42. Pediculosis, head lice and vermin. 50 

43. Ringworm, body and scalp 4 

44. Scabies, itch 5 

45. Tonsilitis, quinsy lO 

B. Infectious Diseases. 

46. Chicken pox 6 

47. Diphtheria 2 

48. Measles 4 

49. Mumps 4 

50. Scarlet Fever 4 

51. Trachoma, "granulated eye-lids" I 

52. Tuberculosis of the lungs, "consumption" I 

53. Tuberculosis of the bones and other parts of the body i 

54. Whooping Cough, Pertussis 2 

Total 1,419 



MEDICAL INSPECTION PLAN 353 

Roughly, I estimate that about one-third of the pupils 
will be found free from serious ailments (and defects), 
another third will be found with teeth defects only, and the 
final third with teeth defects and other ailments. This last 
third will average about three ailments each. 

principals' monthly reports 
On the regular monthly report of the principals to the 
superintendent there should be required a statement as to 
the general status of the medical service in each school with 
a statement as to the regularity, punctuality, and fulfillment 
of the time and schedule requirements of doctors and nurses. 
The report of principals in Trenton, N. J., is very sug- 
gestive but defeats itself by its elaborateness, calling for 
a report for each day of the month on several items and 
the list of ailments found, cured, etc., etc. This is the 
proper work for the school nurse and has been provided for 
in this plan. The principals should be made, however, to 
feel their responsibility for general oversight and leader- 
ship of all health measures in their schools and neighbor- 
hoods. 

CASE CARD SYSTEM 

The blue case cards used in Milwaukee and Newark 
and the one given in Dr. Cornell's book on Medical Inspec- 
tion, page 57, are recommended for study and use, if they 
are found necessary. A book with appropriate headings 
on each page: room, date found, the ailment, recommenda- 
tion, results, etc., for each school can more easily be carried, 
and has some advantages for a small system. See Cornell's 
Record of Defective Children, page 55. The exclusion 
books will also give the record of a number of cases. Each 
school should have its own exclusion-book as well as its own 
nurse's case book, or card index. The work must always 
be reported in terms both of the number of children and 
of the number of ailments. 

THE WORK OF THE TEACHERS 

Teachers and janitors, of course, should be examined 
prior to their entrance to the school system and every two 



354 SCHOOL HEALTH ADMINISTRATION 

to three, or fewer, years thereafter. It is remarkably easy 
for a tubercular teacher to get a clean bill of health from 
a physician, and the periodical examination should be 
made compulsory. Teachers as a class have more than 
their share of tubercular, nervous, and other ailments. 
That the teacher be in good health is a prerequisite to the 
proper health care of her pupils. 

The teacher, also, must be educated for this health work 
as well as the doctors and nurses after they enter the 
system. A valuable medical-supervision library has de- 
veloped in the past four years and each school system 
should provide its teachers with, at least, one simple well 
illustrated book on the subject, say Hoag's "Health Index" 
or CornelPs "Health and Medical Inspection of School Chil- 
dren," F. A. Davis Co., Philadelphia, as well as the other 
educative means discussed. Dresslar's "School Hygiene" 
(Macmillan) is very desirable for the whole health field. 
In the teachers' hands very largely must remain the health 
destines of the children, and this responsibility and this op- 
portunity can never be entirely shifted. 

SUPERINTENDENT'S ANNUAL REPORT ON MEDICAL 
INSPECTION 

Much in the way of progress, records, and education 
of the public depends upon the character of this annual, 
public report. The number of pages of the present reports 
devoted to this subject varies greatly even by percentages. 
South Manchester, Conn., probably gives a larger share of 
its report to these newer health matters than any other 
city. The plan of coming around to health matters every 
few years for intensive and comparative treatment while 
emphasizing certain general features every year is to be 
commended. Some of the features of the regular report 
may well be: 

I. The summary of the weekly reports, which have 
been summarized for the newspapers and for each monthly 
board meeting during the year, both as to ailments and the 
general features given on both sides of the report. 



MEDICAL INSPECTION PLAN 355 

2. Comparison with the worlc of former years. 

3. Interpretation of the data presented. 

4. Some of the interesting cases handled during the 
year, to give the intimate personal side, with photographs, 
if possible. 

5. Emphasis on the percentage of ailments cured. 

6. The principal needs and problems, and what parents 
can do to help. 

7. Appreciative words for the various voluntary health 
agencies that have helped during the year, the newspapers, 
bequests for school clinics, etc. How the various divisions 
of the hygiene department have co-operated. 

8. A general estimate of the health conditions of the 
school children. 

III. MEASURING THE EFFICIENCY OF MEDICAL INSPECTION 

SYSTEMS 

The principal efficiency tests are the percentage of the 
serious ailments existing in the school population that have 
been found and the percentage of the ailments found that 
have been cured. The decrease In ailments found from 
year to year due to prevention and curative measures (not 
to changes In the standards of inspectors) is a third essential 
factor. In another place (chapters on ailments, and in the 
table of ailment frequencies) the writer has given an esti- 
mate of the approximate percentages of serious ailments 
to be found In an ordinary school population at the present 
time with which comparisons may be made. Among a host 
of other tests of efficiency of this work are the following: 

1. Number of physicians and nurses In proportion to the 
school population, and the number of nurses in relation to 
the number of physicians. 

2. The qualifications and the character of the super- 
vision of these officials, 

3. The percentage of the school population Inspected 
and examined, and the frequency of these. 



356 SCHOOL HEALTH ADMINISTRATION 

4. The quality of the reporting system, whether it em- 
phasizes essentials, and whether it promotes accurate records 
with minimum loss of time from other work. 

5. The annual number of hours of work for physicians 
and nurses, and the regularity and punctuality of attendance 
upon such work. 

6. The reasonable freedom from epidemics, closing of 
schools, deaths of school children, large amount of exclu- 
sion, quarantine, illness, absence and elimination, etc. 

7. The quality of the methods of doctors and nurses 
to be determined by expert observation. 

8. The amount of state-aid money obtained because of 
efficiency demonstrated to the State Supervisor of Hygiene. 

REFERENCES 

Some of the literature which will be of value in adapting 
this system to particular cities or rural regions, and the 
first four groups now procurable largely for the writing are : 

1. 1911-12 report of the Chief Medical Officer, Dunfermline, Scot- 
land. 

2. Monograph bulletins on the medical inspection of school chil- 
dren in: 

Board of Education Cities, such as Celveland, St. Louis, South 
Manchester, Conn. (1912 report), Milwaukee, Newark, Trenton, 
Yonkers, Toronto, Canada (Lina H. Rogers), Berkeley, San Jose and 
Oakland, California, College of The City of New York (Dr. Thos. 
Storey, on high school medical supervision). State Board of Education 
of Massachusetts, Boston, etc., Meriden, Conn. 

Board of Health Cities, such as the New York, Chicago, Providence, 
State Board of Health, Connecticut; State Boards of Health of Vir- 
ginia and Kansas (Health Almanacs), etc. 

3. Annual Report of the Chief Medical Officer of the English 
Board of Education, London, England. This gives a list of good city 
and rural reports. 

4. Annual Reports of the Chief Medical Officer for the London 
County Council, London, England. 

5. Books: Monroe's "Cyclopedia of Education," five volumes. 
Health articles. 

Gulick and Ayres, "Medical Inspection of School Children." 
Cornell, "Health and the Medical Inspection of School Children." 
Hoag, "The Health Index of Children." 
Denison's "Helping School Children." 

Wood: "Health and Education," and "The Nurse in Education," 
U. of Chicago Press. 



MEDICAL INSPECTION PLAN 357 

Lina H. Rogers, "The School Nurse," soon to be published. 

Burks "Health and the School," Appleton's. 

Hutt, "Hygiene for Health Visitors, School Nurses, and Social 
Workers," P. S. King & Son, London, Eng. 

Moll, "The Sexual Life of the Child." 

Hutchinson's "Handbook of Health." 

Ditman's "Home Hygiene and the Prevention of Disease." 

Gillette, "Constructive Rural Sociology." 

Kelynack, "Medical Examination of Schools and Scholars," King 
& Son, London, Eng. 

Holmes, "The Conservation of the Child." 

Dresslar, "School Hygiene." 

Terman, "The Teacher's Health." 

"Exercise in Education and Medicine," McKenzie, Saunders Co., 
Philadelphia. 

Shaw^, "School Hygiene." 

Scripture, "Stuttering and Lisping." 

"The Child in the City," by the Chicago School of Philanthropy. 

Putnam, "School Janitors, Mothers and Health," American Acad- 
emy of Medicine Press, Easton, Pa. 

Marshall, "Mouth Hygiene." 

Hoag and Terman, "Health Work in the Schools," in preparation. 

Hutchinson, "Common Diseases." 

Gulick, "Hygiene Series, "Ginn & Co. 

Ritchie, "Hj'giene Series," World Book Co. 

Colton, "The People's Health." 

Holt, "Diseases of Infancy and Childhood." 

McCombs, "Diseases of Children for Nurses." 

Hoxie, "Practice of Medicine for Nurses." 

"The Public Health Movement," The Annals for March, 191 1. 

Ditman, "Education in Preventive Medicine," Columbia University 
Press. 

Wile, "Sex Education." 

Woodworth, "The Care of the Body." 

Hough and Sedgwick, "The Human Mechanism." 

Rapeer, "Educational H^'giene" and "School Health," in preparation. 

Lippert and Holmes, "When to Send for the Doctor." 

Sandiford, "The Mental and Physical Life of Children," Longmans. 

Sill, "The Child." 

"Annotated Bibliography of Medical Inspection and Health Super- 
vision of School Children in the United States for the years 1909-1912," 
a free bulletin (No. 524) by the U. S. Bureau of Education, Wash- 
ington, D. C. 

"A Bibliography on Educational Hygiene," by Thos. Wood and 
Mary Reesor. M. A., Teachers College, Columbia University, 1911, 

"Annotated List of Text and Reference Books for the Training 
School for Nurses," prepared by the Department of Nursing and 
Health, Teachers College, Columbia University. 

See also the biblography prepared by the author for his section on 



358 SCHOOL HEALTH ADMINISTRATION 

"The Hygiene of the High School" in Johnston's "High School Edu- 
cation," Vol. n. 

6. Bureaus: The Division of Child Hygiene, Sage Foundation, 
N. Y. City. 

Bureau of Municipal Research, N. Y. City. 

United States Bureau of Education. 

Reports of the National Education Association, Educational Hygiene 
Articles. 

The Journal of the American Medical Association, Chicago, re- 
ports on medical supervision. 

Proceedings of the National and of the International School Hygiene 
Congresses. 

7. Magazines: Current educational and other literature has many 
articles on these subjects, all of which can be found in any of the guides 
to periodical literature found in any public library. 

*See also the bulletin of the U. S. Bureau of Education No. 524, 
pp. 130-131; and Dr. Dresslar's article on "Typical Health Teaching 
Agencies of the United States" in the 1912 report of the U. S. Com- 
missioner of Education, Vol. I. 



INDEX 



Abscess, 182. 

Adenitis, 170. 

Abstract of the book, 7-13. 

Adenoids, 141. 

Administration of Educational Hy- 
giene, 11. 

Administration, general (tables), 76- 
77. 

Agencies, Health, 56. 

Ailments of School Children, 138 ; 
summarized, 225 ; tables, 226, etc. 

Anemia, 147. 

Annual Report of Supt., 350. 

Ayres, Dr. L. P., 32, 38. 

Bachman, Dr. Frank, 36. 

Backward children, 176. 

Biggs, Dr., 25. 

Binet tests, 177. 

"Bladder trouble," 202. 

Blepharitis, 196. 

Boards of Education vs. Boards of 

Health, 83, 166, 243, 247. 
Boils, 182, 

Books on Educational Hygiene, 135. 
Boy Scouts, 272, 273. 
Broome, Supt. E. C, 40. 
Bronchitis, 183. 
Brubacher, Supt. A. R., 45. 
Budget exhibits, 241. 
Burnham, Prof. Wm. H., 272. 

Cabot, Dr. Arthur T. (deceased), 303. 

Case card system, 349. 

Catarrh, 189. 

Chapin, Dr. C. V., 166. 

Checks on Work of Doctors and Nurses, 

95. 
Chest defects, 179. 
Chicken Pox, 215. 
Children's bureau, 57. 
Chorea, 177. 

Cities, The twenty-flve, 75, 254. 
Classification of ailments, 135, 352. 
Cleanliness needed, 187. 
Clement, Sect. F. F., 304. 
Clinics, 155, 228, 232, 306. 
Colds, 190. 
Colton's "Handbook of the People's 

Health," 288. 
Common non-infectious ailments, 182, 

184, 185. 
Communicable ailments, tables, 205-7. 
Conclusions on Medical Inspection, 

257. 
Conjunctivitis, 204. 
Consultations with mothers, 241. 
Consumption, 222. 
Contagious ailments, 203. 
Cornell, Dr. W. S., 98. 
Coryza, 190. 

Cost of Medical Supervision, 86. 
Crandall, Prof. Ella P., 304. 
Cross-eye, 168. 
Cruickshank, Dr. L. D., 244. 
Cures, 131. 

Davenport, Dr. Chas. B., 16, 65. 

Deafness, 148. 

Death : causes, 22 ; in the 25 cities, 

207 ; losses, see "Economic." 
DebiTity, 175. 

Defective pupils, percentage, 129, 352. 
Deformities, 179. 



Demarest, Supt. A. J., 37. 

Dental defects, 151. 

Desks, school, 284. 

Dewey, Prof. John, 14. 

Diphtheria, 216. 

Directions for making reports, 346. 

Disinfection, 242. 

Doctors and nurses : number, 78-79 ; 

work, 80-81. 
Doctor's examinations, 333. 
Dressier, Prof. F. B., 66. 
Drinking fountains, 282. 
Dunfermline, 178, 189. 
Dust absorbing compounds, 285. 

Ear ailments, minor, 194 ; discharge 
(otitis), 192. 

Economic losses from ill health, 8-9, 
21-27, 30-33. 

Eczema, 195. 

Educational Hygiene : divisions of, 296. 

Efficiency tables, 253. General effi- 
ciency, 351. 

Elimination, 34. 

Eneuresis, 202. 

Enlarged tonsils, 157. 

Epistaxix, 198. 

EugenicSj 65. 

Examinations : 100, 102, 113 ; num- 
ber, 120 ; vision, 123, 327. 

Expenditures for Medical Supervision, 
299, 301. 

Exclusions : and retardation, 46 ; form 
and method, 319-320. 

Eyes, minor ailments, 196. 

Eyesight, 122, 161. 

Farr, 32. 
Favus, 208. 
Feeding, 175-176. 
First-aid, 201. 
Fiscal fallacy^ 219. 
Fisher, Prof. Irving, 18-30. 
Flexner, Dr. A., 18. 
Foley, Sect. Edna L., 304. 
Foster, Dr. N. K., 303. 
Fountains, drinking, 282. 
Frequency of ailments, 226-227, 248- 
349, 352. 

Giddings, Prof. F. H., 309. 

Glands enlarged, 170. 

Glasses, 167. 

Goddard, Prof. H. H., 177. 

Gorgas, W. C, 54. 

Grippe, 209. 

Gulick, Dr. Luther H., 26, 272, 288. 

Gymnasiums, 275. 

Hall, President G. S., 294. 

Health agencies, 55-60. 

Health record cards, 311, 315. 

Hearing : 148 ; tests, 332. 

Heredity, 65. 

Hermann, Dr. Ernst. 266. 

High School Medical Supervision, 104, 

258-259, 273-277. 
Hoag, Dr. E. B., 134. 
Holmes, Dr. Geo. J., 96. 
Home visits, 325. 
Howerth, Prof. Ira S., 70. 
Hygiene of School Room, 61. 
Hygiene of Teaching or "Instruction, ' 

289, 296. 



359 



36o 



INDEX 



Illness losses, summary, 47. 

Impetigo, 209. 

Infectious diseases, 214 ; table, 207. 

Influenza, 209. 

Inspections, 124, 127. 

Investigations, health, 243. 

Itch (scabies), 212. 

Johnston, Prof. Chas. H., 259, 269. 

Keyes, Dr. Chas. H., 33-34. 

Lamson, Dr. W. J., 152. 

Laryngitis, 197. 

Laws on Meflical Inspection, 62. 

Lectures, 236. 

Lice, 209. 

Lisping, 180. 

Locke and Floyd, 23. 

Lungs weak, 10. 

Lubin Vitagraph Co., 57. 

Mackey, Supt. E., 42. 

McKenzie, Prof. R. T., 276. 

Malnutrition, 175. 

Measles, 220. - 

Medical attendance expense, 24. 

Medical Supervision, divisions of, 305. 

Medical supplies, 93, 232. 

Mentality defective, 176. 

Method of inspection, 308, 317. 

Mortality statistics, 19. 

Mothers' consultations, 241. 

Mouth hygiene, 151. 

Mumps, 221. 

National vitality, 21. 
Nearing, Prof: Scott, 23. 
Negative cases, 144. 
Nervous ailments, 177. 
Neuralgia, 197.' 
Neurologists, 236. 
Newman, Sir Geo., 145. 
Nomenclature, tentative standard, 352. 
Nose-bleed, epistaxis, 198. 
Notice to parents, 335. 
Nurse-alone plan, 302. 
Nurses : where to get them, 304 ; in- 
spection by, 127. 
Nutritional index, 176. 
Nutting, Prof. M. A., 304. 

Oculists, 236. 

Oils, floor, 285. 

Open-air schools, 239. 

Orthopedic defects, 179. 

Otitis media ear discharge, 192. 

Otorrhea, 192. 

Palate defects, 179. 
Parental education, 339. 
Part-time physicians, 303. 
Pasteur, Louis, 18. 
Pediculosis, 209. 
Pertussis, whooping cough, 224. 
Pharyngitis, 198. 

Physical defects, 134, 141, 352 ; sum- 
mary table, 184. 
Physical education, 296 ; table, 263. 
Pink eye, conjunctivitis, 204. 
Playgrounds, 64, 276. 
Posture, 179. 
Prescriptions, 235. 
Prevention, 239. 

Preventable deaths, 18,-20, 29-30. 
Principals' reports, 349. 
Private organizations, 237. 
Promotion, 34. 
Public health,' 17. 

Quarantine and retardation, 46. 
Quinsy, 213. , 



Ranking of the 25 cities, 254. 
Reports of doctors and nurses, 341 

and 343-4. 
Retardation, 34. 
Reik, Dr. H. O., 158, 168. 
Rheumatism, 198. 
Rhinitis, 189. 
Ringworm, 211. 
Ritchie Hygiene Series, 288. 

Salaries of physicians and nurses, 87, 

90. 
Salaries, 75. 
Sanitary inspection of home and school, 

280, 296, 326. 
Scabies, itch, 212. 
Scarlet fever, 221. 
Schedules, 99. 
School children, death losses, 28, 29, 

30. 
School Board Journal, 275, 283. 
Scientific management, 298. 
September classroom inspections, 307. 
Sex ailments, 199. 
Shoulders, round, 179. 
Signs for medical inspection reports, 

310. 
Skeletal defects, 179. 
Skin ailments, minor, 200. 
Sore throat, acute, 182. 
Speech defects, 180. 
Spinal curvature, 179. 
Squint, 168. 
Standardization of medical inspection, 

305-306. 
Statistical fallacies, 31. 
Stomatitis, 200. 
Storey, Dr. Thos., 105, 258. 
Strabismus (cross-eye or squint), 168. 
Stuttering and stammering, 180. 
Strayer, Prof. G. D., 6, 29, 32. 
Styes, 196. 
Supplies for medical supervision, 92, 

232. 
Summaries 7, 47, 64, 107, 257, 290. 
Supervisor of hygiene 297. 
Suzzallo, Prof. Henry, 6. 

Teacher's medical inspection, 349. 

Teaching hygiene, 287, 296. 

Teeth defects, 151. 

Tendencies in medical supervision, 84. 

Terman, Prof. L. M., 72. 

Thorndike, Prof. E. L., 6. 

Treatments, 231. 

Throat, sore, 182. 

Time employed in medical supervision, 

94. 
Tonsolitis, 213. 
Tonsils, enlarged, 157. 
Towels, paper and cloth, 286. 
Trachoma, granulated eye-lids, 222. 
Tubercular glands, 170. 
Tuberculosis, of lungs, 222 ; of bones, 

etc., 224. 

Urinary ailments, 202. 

Vaccination, 339. 
Vacuum cleaning, 283. 
Verplanck, Supt. F. A., 43. 
Vision defects, 161, 163, 122. 
Vision tests, 330. 

Wallace, A. R., 65. 

Wallin, Prof. J. B. W., 48. 

Whooping cough, 224. 

Wilcox, 19. 

Work certificate examinations, 102, 

242. 
Wounds, sores, sprains, etc., 201. 



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